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A  TEXT-BOOK 

OF 

OBSTETRICS 

BY    BARTON    COOKE    HIRST,    M.D. 

PROFESSOR     OF     OBSTETRICS     IN     THE    UNIVERSITY     OF     PENNSYLVANIA; 

GYNECOLOGIST  TO   THE   HOWARD,  THE   ORTHOPEDIC,  AND 

THE   PHILADELPHIA   HOSPITALS,  ETC. 


Sixth      Edition,      Revised     and      Enlarged 

with 
847    Illustrations,    43    of    them    in    Colors 


PHILADELPHIA  AND  LONDON 

W.     B.    SAUNDERS     COMPANY 

1909 


Set  up,  electrotyped,  printed,  and  copyrighted  November,  iggS.     Revised, 
reprinted,   and    recopyrighted   May,   1899.     Reprinted    May,   1900. 
Revised,    reprinted,    and      recopyrighted     April,  1901.       Re- 
printed  December,   1901.     Revised,   reprinted,  and  re- 
copyrighted  July,     1903.      Reprinted    July,   1905. 
Revised,  reprinted,  and  recopyrighted   Au- 
gust,  1906.    Reprinted  October,  1907. 
Revised,      reprinted,    and      re- 
copyrighted    July,     1909. 


Copyright,  1909,  by  W.  B.  Saunders  Company. 


PRINTED    IN    AMERICA 


PRESS    OF 
SAUNDERS    COMPANY 
PHILADELPHIA 


o 


TO 

RICHARD   A.  F.  PENROSE,  M.D.,  LL.D. 

EMERITUS   PROFESSOR   OF   OBSTETRICS  AND  OF  THE    DISEASES  OF  WOMEN  AND 
CHILDREN   IN   THE    UNIVERSITY    OF   PENNSYLVANIA 

XLhie  :SBoo\{  is  ©ratcfuUis  BeMcatcD 

BY  HIS  FORMER   PUPIL,  THE  AUTHOR 


■•.4.v?345 


PREFACE  TO  THE  SIXTH  EDITION. 


The  revision  for  the  sixth  edition  has  been  thorough.  The 
most  extensive  additions  have  been  made  in  the  section  on  oper- 
ations, which  now  includes  the  operations  for  the  compHcations 
and  consequences  of  the  child-bearing  process  at  all  periods — 
that  is  to  say,  all  the  gynecologic  operations.  ]\Iany  works  on 
obstetrics  are  curiously  deficient  in  this  respect.  Pan-hysterec- 
tomy for  chorio-epithelioma  is  as  much  an  obstetric  operation 
as  the  application  of  forceps.  It  is  illogic  to  recommend  the 
operative  treatment  for  retroversion  of  the  uterus  following  child- 
birth ;  salpingo-oophorectomy  for  ectopic  pregnancy  and  the 
infections  of  the  puerperium;  supravaginal  hysterectomy  for 
fibromyoma  or  for  the  Porro-Cesarean  section;  the  plastic  oper- 
ations for  injuries  of  the  genital  canal,  and  then  to  tell  students 
nothing  about  the  kind  of  operation  to  select  or  the  technic  of 
its  performance.  x\n  effort  has  also  been  made  to  present  a 
brief  account  of  the  diagnosis  and  treatment  of  all  the  pathologic 
phenomena  peculiar  to  women,  which  is  the  proper  scope  of  a 
work  on  obstetrics. 

All  the  diseases  of  women  must  be  considered  in  relation  with 
the  chief  act  in  woman's  history,  child-bearing.  The  vast  major- 
ity of  them  are  consequences  of  that  i)rocess.  All  of  them  arc  pos- 
sible complications.  Consequently,  the  s])ecialist  in  this  l^ranch 
of  medicine  must  be  an  expert  in  every  department  of  gynecology. 
In  fact,  he  is  the  only  specialist  qualified  as  an  expert  by  com- 
mand of  clinical  material,  by  extent  and  variety  of  experience. 
It  is  not  sur])rising,  therefore,  lliat  the  l)ulk  of  this  work  is  com- 
ing into  his  hands  in  America  as  all  of  it  long  ago  came  into  the 
hands  of  his  colleagues  in  the  older  medical  centers  of  the  world. 
To  maintain  his  reputation,  retain  his  practice,  and  escape  legal 
res])onsibility  the    general   physician  also   must   l)e   prepared   at 

9 


lO  PREFACE    TO    THE   SIXTH  EDITION. 

least  to  make  diagnoses  and  to  give  proper  advice  on  all  the 
complications  and  consequences  of  child-bearing,  and  on  the 
relations  between  the  diseases  of  women  and  that  process. 

A  number  of  new  illustrations  have  been  introduced;  some 
of  the  older  ones  have  been  discarded.  The  literature  has  been 
carefully  reviewed.  Whatever  study  or  personal  experience  has 
demonstrated  to  be  an  advance  of  real  value  has  been  intro- 
duced into  the  text. 

1821   Spruce  Street,  Philadelphia. 
June,  1909. 


PREFACE. 


This  work  is  the  result  of  a  practice  devoted  for  the  past 
twelve  years  exclusively  to  gynecology  in  both  its  branches — 
obstetrics  and  gynecic  surgery.  The  author  has  served  during 
this  period  as  consulting  and  attendant  gynecologist  and  obstet- 
rician in  eight  of  the  principal  hospitals  of  Philadelphia.  His 
experience  in  obstetrical  complications  and  operations  has  con- 
sequently been  exceptionally  large.  He  has  been  engaged, 
moreover,  during  the  whole  of  his  professional  career,  in 
teaching  medical  students  in  clinics,  hospitals,  laboratories,  and 
in  the  lecture-room.  He  ventures  to  entertain  the  hope,  there- 
fore, that  his  training  has  fitted  him  for  the  preparation  of  a 
book  which  shall  serve  as  a  guide  to  undergraduate  students  and 
to  physicians  in  active  practice.  It  has  been  his  constant  aim  to 
condense  the  text  as  far  as  is  consistent  with  a  comprehensive 
treatment  of  the  subject.  Illustrations  have  been  extensively 
employed,  the  majority  of  them  from  original  photographs 
and  drawings.  The  task,  impossible  within  a  single  volume,  of 
presenting  a  complete  bibliography  of  each  subject  has  not  been 
attempted.  The  student  who  desires  such  information  is  referred 
to  the  "  Catalogue  of  the  Surgeon-General's  Library,"  the  ten 
volumes  of  the  "  Jahresbericht  uber  die  Fortschritte  auf  dem 
Gebiete  der  Geburtshilfe  und  der  Gynakologie,"  and  to  the  "  In- 
dex Medicus."  References  are  given  to  articles  and  books 
which  have  been  most  helpful  to  the  author  or  which  have  been 
epoch-making  in  the  history  of  obstetrics. 

1821  Spruce  Street,  Philadelphia. 


11 


CONTENTS 


PAGE 

PART  I— PREGNANCY 17 

Chapter  I. — Anatomy 17 

Anatomy  of  the  Pelvis    ,    .    .    ; 17 

The  Female  Sexual  Organs 39 

Chapter  II. — Menstruation,  Ovulation,  Fertilization,  etc.  .    .  57 

Menstruation 57 

Ovulation      .         61 

The  Corpus  Luteum ,  64 

The  Connection  between  Ovulation  and  Menstruation 65 

Insemination 67 

The  Causes  and  Treatment  of  Sterility 75 

Changes  in  the  Ovum  following  Impregnation 78 

Chapter  III. — The   Development  of  the  Embryo  and  Fetus   .  80 

Development  during  the  Months  of  Pregnancy 80 

The  Mature  Fetus        91 

Chapter  IV. — The  Fetal  Appendages 98 

The  Amnion 98 

The  Chorion •    •  no 

The  Placenta 120 

The  Umbilical  Cord  or  Funis 13^ 

The  Decidu3e I43 

Chapter  V. — The  Diseases  of  the  Fetus 155 

Chapter  VI. — The  Physiology  of  Pregnancy 180 

Changes  in  the  Uterus i"0 

Changes  in  the  Several  Systems  of  the  Body 185 

The  Diagnosis  of  Pregnancy 189 

Chapter  VII. — Pathology  of  the  Pregnant  Woman 215 

Diseases  of  the  Genitalia 215 

Diseases  of  the  Uterine  Muscle 222 

Diseases  of  the  Alimentaiy  Canal 237 

Diseases  of  the  Urinary  Apparatus 244 

Diseases  of  the  Nervous  System 254 

Diseases  of  the  Circulatory  Apparatus 257 

Diseases  of  the  Respiratory  Apparatus 261 

Diseases  of  the  Osseous  System 263 

13 


14  CONTENTS. 

PAGE 

Infectious  Diseases 263 

Skin  Diseases ,    .  264 

Abortion,  Miscarriage,  and  Premature  Labor 267 

Extra- uterine  Pregnancy 284 

PART    II.— THE     PHYSIOLOGY    AND     MANAGEMENT     OF 

LABOR  AND  OF  THE  PUERPERIUM .312 

Chapter  I. — Labor 312 

Chapter  II. — The  Puerperal  State 347 

PART  III.— THE  MECHANISM  OF    LABOR. 388 

Forces  Involved  in  the  Mechanism  of  Labor  . 39^ 

Mechanism  of  the  Several  Presentations  and  Positions 395 

Abnormalities  of  Mechanism  and  their  Management 4°^ 

Mechanism  of  the  Third  Stage  of  Labor 433- 

PART  IV.— THE  PATHOLOGY  OF  LABOR 439 

Chapter  I. — Dystocia 439 

Abnormalities  in  the  Forces  of  Labor 439 

Labor  Complicated  by  Accidents  and  Diseases ST^ 

Dystocia  Due  to  Disease "^7 

PART  v.— PATHOLOGY  OF  THE  PUERPERIUM      ......  644 

Chapter  I. 

Abnormalities  in  the  Involution  of  the  Uterus  after  Child-birth  .  644 

Puerperal  Hemorrhages 649 

Non-infectious  Fevers 665 

Acute  Intercurrent  Affections 672 

The  Exanthemata 674 

Puerperal  Diphtheria •.  681 

Puerperal    Malaria ,    .    .    .        .    .    .    .' 681 

Rheumatism  and  Arthritis 683 

Gonorrhea 685 

Skin  Di.seases 686 

Diseases  of  the  Abdominal  Muscles 686 

Tympanites 686 

Diseases  of  the  Urinary  System 687 

Diseases  of  the  Nervous  System   .    .    .    r 692 

Developmental  Anomalies  of  the  Breast 693 

Anomalies  in  Milk  Secretion 695 

Diseases  of  the  Mammary  Glands 7^4 

Relaxation  of  the  Pelvic  Joints 7" 

Chapter  IL — Puerperal  Sepsis 712 

PART  VI.— OBSTETRIC  OPERATIONS 773 

Chapter  I. — Aseptic  and  Operative  Technique  in  General  .    .  773 

The  Hospital  Operating-room 773 

The  Private  House  Operating-room 775 

The  Operating  Table 777 

Hand  and  Skin  Cleansing;  the  Surgeon's  Dress 778. 


CONTENTS.  1 5 

PAGE 

The  Preparation  of  the  Patient 780 

Ligatures  and  Sutures 7^2 

Anesthetics  ;    Instruments 7^3 

Chapter    II. — The    Artificial   Dilatation    of   the    Cervical 
Canal  and  the  Operations  to  Deliver  the  Embryo 

AND  Fetus 7^4 

Hydrostatic  Dilatation .     784 

Manual  Dilatation 786 

Instrumental  Dilatation 787 

Dilatation  by  Incisions 795 

Vaginal  Cesarean  Section 795 

Induction  of  Abortion 797 

Induction  of  Labor 799 

Forceps 800 

Extraction  of  the  Breech 824 

Version , 827 

Embryotomy 842 

Symphyseotomy 850 

Hebotomy 854 

Cesarean  Section 855 

Extraperitoneal  Cesarean  Section 861 

Chapter  III.— Operations  for  the  Complications  and  the  Path- 
ological Consequences  of  the  Child-bearing  Process  .    862 

Preparation  for  Operations  in  the  Lower  Birth  Canal 864 

Operations  on  the  Vulva 864 

Operations  on  the  Vagina 867 

Lacerations  of  the  Posterior  Wall 867 

Lacerations  of  the  Anterior  Wall 874 

Fistulse  between  the  Genital  and  Urinary  Canals   ....     875 

Operations  for  Acquired  Stenosis  and  Atresia 893 

Operations  on  the  Cervix:  Vaginal  Section  (Colpotomy)  .    .    .    .     897 

Myomectomy  by  the  Vaginal  Route 899 

Preparation  for  Abdominal  Operations  :  The  Incision,  the  Closure 

of  the  Wound,  Dressing,  Drainage 899 

Hysterectomy.:    Partial,  Total,  Vaginal,  Combined 902 

Salpingo-oophorectomy       9^4 

Excision  of  Pelvic  and  Abdominal  Tumors  by  Alidominal  Section    910 

Inguinal  Section 9'' 

AlDdominal  Operations  for  Retrodisplacement  of  the  Uterus     .    .     917 
Operation   for   Diastasis   of   the   Recti   Muscles    and   Abdominal 

Hernia 9'9 

Coccygectomy 9^- 

PART  VII.— THE  NEW-BORN   INP^ANT 923 

Chapter  I. — Physiology  of  the  Nkvv-hokn  Infant 923 

Chapter  II. — Pathology  oi'  the  New-horn  Infant 032 

Injuries  to  tlic  Infant  during  Labor 932 

Diseases  of  the  New-ljorn  Infant 941 

INDEX 955 


A  TEXT-BOOK 


OBSTETRICS. 


Introduction. 

"Obstetrics,"  derived  from,  a  Latin  word  meaning  to  stand  in 
front  of,  as  a  midwife  stood  or  knelt  before  her  patient  on  the  birth 
stool,  originally  signified  the  assistance  afforded  a  woman  in  labor. 
Its  modern  significance  is  wider.  It  includes  a  study  of  the 
physiology  and  pathology  of  conception,  gestation,  parturition, 
and  the  puerperium,  with  all  the  complications  and  pathologic 
consequences  of  the  child-bearing  act  at  all  periods.  It  embraces, 
therefore,  a  study  of  all  the  diseases  peculiar  to  women. 


PART  I. 
PREGNANCY. 


CHAPTER  I. 

Anatomy   of  the  Pelvis ;    Development   and   Anatomy  of  the 
Female   Generative  Orgfans. 

THE  ANATOMY  OF  THE  PELVIS. 

The  hip-bones  together  with  the  sacrum,  including  the 
coccyx,  compose  the  pelvis,  which  forms  the  basin-like  lower 
portion  of  the  trunk.  In  the  erect  position  of  the  body  the 
pelvis  is  bent  obliquely  backward  from  the  vertebral  column 
above,  so  that  the  crest  of  the  pubis  descends  nearly  to  a  level 
with  the  end  of  the  sacrum.  The  pelvis  is  divided  into  two  parts 
by  a  prominent  rim,  named  the  brim  of  the  pelvis,  which  is 
formed  on  each  side  by  the  iliopectineal  line  continued  behind 
the  crest  of  the  pubis  and  by  the  curved  ridge  and  promontory 
of  the  sacrum.  The  upper  part  is  formed  by  the  ilia,  and 
includes  the  widest  space  of  the  pelvis  which  pertains  to  the 
abdominal  cavity.  The  lower  part  is  distinguished  as  the  true 
pelvis,  and  incloses  the  cavity  of  the  pelvis.  It  is  a  complete 
bony  girdle,  formed  by  the  sacrum  and  coccy.x,  the  ischium  and 
pubis,  and  a  small  portion  of  the  ilium.  The  upper  extremity 
2  17 


1 8  PREGNANCY. 

of  the  pelvic  cavity,  corresponding  with  the  brim,  is  the  inlet,  or 
superior  strait ;  the  lower  extremity  is  ^he  outlet,  or  inferior 
strait.  In  consequence  of  the  curvature  of  the  sacrum  and 
coccyx  the  pelvic  cavity  appears  as  a  curved  cylinder,  slightly 
narrowed  toward  the  outlet.  It  is  deepest  behind  and  shallowest 
at  the  pubic  symphysis.  Its  lateral  wall  is  deep  and  vertical. 
It  extends  from  the  iliopectineal  line  to  the  end  of  the  ischial 
tuberosity,  and  is  mainly  formed  by  the  body  of  the  ischium 
with  small  portions  of  the  iHum  and  pubis.  The  anterior  depth 
of  the  pelvis  (height  of  the  symphysis)  is  4  cm.  (1.57  in.).  The 
lateral  depth  is  9  cm.  (3.54  in.).  The  posterior  depth  is  13  cm. 
(5.12  in.). 

The  pelvic  inlet  is  cordiform,  with  the  notched  base  con- 
forming with  the  base  of  the  sacrum  and  the  rounded  apex 
with  the  pubes.  The  outlet,  rather  smaller  than  the  inlet,  when 
completed  by  the  great  sacrosciatic  ligaments  has  the  same 
shape,  with  the  notched  base  formed  by  the  coccyx  and  the  apex 


Fig.  I. — P'emale  pelvis  (one-third  natural  size)  (Dickinson). 

by  the  pubic  symphysis.  Its  fore  part  is  the  pubic  arch,  the 
base  of  which  extends  between  the  ischial  tuberosities  ;  and  the 
sides  are  formed  by  the  conjoined  rami  of  the  pubes  and  ischia. 
On  each  side  of  the  outlet  is  the  deep  sacrosciatic  notch,  formed 
in  front  by  the  ischium,  above  by  the  ilium,  and  behind  by  the 
sacrum  and  coccyx.  It  is  converted  into  the  great  and  small 
sciatic  foramina  by  the  sacrosciatic  ligaments,  which  also  sepa- 
rate them  from  the  pelvic  outlet.  The  pelvis  of  the  female  not 
only  differs  from  that  of  the  male  in  accordance  with  the  usual 


THE  ANATOMY  OF   THE   PELVIS. 


19 


difference  in  other  parts  of  the  skeleton,  but  also  exhibits  impor- 
tant modifications  which  relate  to  the  sexual  function.  The 
female  pelvis  is  proportionately  larger,  but  of  more  delicate  con- 
struction. It  is  proportionately,  and  often  absolutely,  of  greater 
breadth,  and  is  of  less  depth.  The  ilia  spread  more  laterally,  so 
as  to  produce  greater  breadth  or  prominence  of  the  hips  than  in 
the  male.  The  true  pelvis  has  greater  horizontal  capacity,  less 
depth,  and  is  commonly  less  curved  and  less  contracted  at  the 
outlet.  The  inlet  is  larger,  less  intruded  upon  by  the  sacral 
promontory,  and  is  more  circular  or  transversely  oval.  The 
outlet  is  likewise  larger,  with  the  ischial  tuberosities  less  conver- 
gent, and  with  the  pubic  arch  wider,  lower,  more  truly  arched, 
and  with  the  sides  more  everted. 


Fig.   2. — The  funnel-shaped  false  pelvis. 


In  the  female  the  sides  of  the  pubic  arch  are  narrower,  more 
flattened,  and  less  ridged  than  in  the  male.  ^ 

The  hip  or  innominate  bones — in  the  adult  a  single  piece — 
are  composed,  in  fetal  life  and  in  childhood,  of  three  separate 
bones, — the  ilium,  the  ischium,  and  the  pubis.  The  three  bones 
are  united  by  a  triradiate  cartilage  in  the  acetabulum,  which 
begins  to  ossify  at  puberty,  the  ankylosis  being   complete  in  the 

^  This  brief  anatomical  description  of  the  pelvis  is  taken,  modified,  from  Leidy's 
"  Anatomy." 


20 


PREGNANCY. 


eighteenth  year.  The  descending  ramus  of  the  pubis  and  the 
ramus  of  the  ischium  are  also  originally  united  by  a  cartilage 
which  ossifies  at  about  the  eighth  year. 

The  bony  pelvic  girdle  in  the  adult  is  united  by  three  joints, 
the  symphysis  pubis  and  the  two  sacro-iliac  joints.  The  former 
is  a  synchondrosis;  the  junction  of  the  pubic  bones  by  the  inter- 
vening cartilage  is  strengthened  by  ligaments  above,  before, 
behind,  and  below  the  symphysis.  The  last  named  is  the  strong- 
est. It  is  the  arcuate  ligament  of  the  pubis.  The  pubic  junction 
will  withstand  a  weight  of  197  kg.  before  rupturing  (Selheim). 
The  sacro-iliac  joints  are  true  joints  (amphiarthroses),  with  all 
their  characteristic  features.  The  joint  surface  of  the  sacrum  is 
broader  behind  and  above  than  it  is-  before  and  below,  so  that  the 
sacrum  cannot  be  pushed  forward  or  downward  without  separat- 
ing the  innominate  bones.  The  joints  are  reinforced  by  com- 
paratively weak  ligaments  anteriorly,  but  by  strong  Hgaments  pos- 
teriorly, the  best  developed  of  which  are  the  sacro-iliac  ligaments. 
The  sacro-ihac  joints  withstand  a  pressure  of  160  to  310  kg._ 

The  Anatomy  of  the  Pelvis  Obstetrically  Considered. — To 
the  obstetrician  the  pelvis  is  a  canal  and  not  a  basin,  and  is  to 
be  studied  mxainly  in  its  relation  to  the  fetal  body  which  must 

pass  through  it. 
The  false  pelvis 
is  of  minor  im- 
portance, acting 
simply  as  a 
funnel-shaped 
structure  to  di- 
rect the  present- 
ing part  toward 
and  into  the 
superior  strait 
of  the  true  pel- 
vis. The  ob- 
stetrical study  of 
pelvic  anatomy 
may  be  confined 
to  the  shape, 
size,  position, 
and  direction 
of  the  true  pel- 
vis. 

Pelvic  Shape. — The  pelvis  might  be  described  as  a  trimcated 
cylinder,  but  the  description  would  not  be  exactly  accurate.^  As  a 
matter  of  fact,  the  pelvic  canal  is  of  different  shapes  at  different 
levels,  and  it  is  necessary  to  study  certain  typical  planes  of  the  pelvis 


Fig.  3. — The  shape  of  the  superior  strait. 


THE   ANATOMY   OF   THE   PELVIS. 


21 


in  order  to  understand  fully  the  relationship  of  fetal  to  pelvic 
shape  in  labor.  The  first  of  these  imaginary  planes  is  laid  at 
the  entrance  to  the  pelvic  cavity  or  canal,  the  pelvic  inlet  or 
superior  strait,  and  is  bounded  by  the  promontory  of  the  sacrum, 
the  iliopectineal  lines,  the  crests  of  the  pubis,  and  the  upper 
edge  of  the  symphysis.  The  shape  of  the  pelvic  inlet  is  cordi- 
form.  In  the  bays  on  either  side  of  the  promontory  rest  the 
important  nerve-trunks  and  blood-vessels  of  the  pelvis,  where 
they  are  guarded  from  the  pressure  of  the  fetal  head.  It  was 
thought  formerly  that  the  shape  of  the  pelvic  inlet  was  elliptical, 
but  this  is  only  exceptionally  the  case,  as  in  certain  justominor 
pelves,  in  which  the  nerve-trunks  and  vessels  may  be  subjected 
to  such  excessive  pressure  that  disease  and  disability  result. 

In  studying  the  pelvic  canal  from  above  downward  it 
appears  that  the  canal  expands  below  the  pelvic  inlet  and  then 
contracts  again  as  it  approaches  the  outlet.  It  is  convenient, 
therefore,  to  lay  off  a  plane  at  the  level  of  greatest  expansion 
and  another  at  the  level  of  greatest  contraction,  which  are  called, 
respectively,  the  plane  of  pelvic  expansion  and  the  plane  of 
pelvic  contraction.  The  shape  of  the  pelvic  canal  at  the  plane 
of  pelvic  expansion,  passing  through  the   middle   of  the   sym- 


Fig.  4. — The  diameters  of  the  superior  strait. 


physis,  the   top  of  the  acetabula,  and  the  sacrum,  between  the 
second  and  third  vertebrs,  is  almost  exactly  circular,  being  only 


22  PREGNANCY. 

a  trifle  larger  in  its  anteroposterior  than  in  its  transverse  diameter. 
The  shape  of  the  pelvic  canal  at  the  plane  of  pelvic  contraction, 
passing-  through  the  tip  of  the  sacrum,  the  spines  of  the  ischia, 
and  the  lower  surface  of  the  symphysis,  is  distinctly  elliptical, 
being  a  centimeter  longer  anteroposteriorly  than  it  is  transversely. 

Finally,  the  shape  of  the  pelvic  outlet,  or  inferior  strait,  is 
cordiform,  from  the  projection  forward  of  the  tip  of  the  sacrum 
and  the  coccyx. 

Pelvic  Size — In  determining  the  size  of  an  irregularly  shaped 
canal  like  that  of  the  pelvis  it  is  necessary  again  to  resort  to 
certain  typical  planes  at  different  levels,  and  to  measure  typical 
diameters  in  these  planes.  Beginning  with  the  cordiform  pelvic 
inlet  it  is  obvious  that  its  dimensions  may  best  be  expressed  by 
the  following  diameters  :  Aii  anteroposterior  diameter  measured 
from  the  middle  of  the  promontory  of  the  sacrum  to  the  sym- 
physis pubis,  about  3. 17  mm.  (^  in.)  below  its  upper  edge; 
this  measurement  averages,  in  the  well-developed  Caucasian 
woman,  11  cm.  (4.33  in.). 

A  transverse  diameter,  \\\&  longest  distance  from  side  to  side  of 
the  pelvic  inlet,  measuring  on  the  average  13.5  cm.  (5.32  in.),  and 
two  oblique  diameters,  the  right  from  the  top  of  the  right,  the  left 
from  the  top  of  the  left  sacro-iliac  junction  to  the  opposite  ilio- 
pectineal  eminences,  measuring  12.75  ^m.  (5.02  in.).  At  the 
plane  of  pelvic  expansion  it  is  possible  to  measure  but  two 
diameters,  an  anteroposterior  and  a  transverse  ;  the  former  is 
12.75  cm.  (5.02  in.),  the  latter,   12.5  cm.  (4.92  in.). 

At  the  plane  of  pelvic  contraction  the  anteroposterior  diam- 
eter is  1 1.5  cm.  (4.43  in.),  the  transverse,  10.5  cm.  (4.13  in.).  At 
the  inferior  strait  the  anteroposterior  diameter,  measured  from  the 
tip  of  the  coccyx  to  the  lower  edge  of  the  symphysis  pubis,  is  9. 5 
cm.  (3.74  in.)  ;  but  this  is  not  a  fixed  measurement,  as  the  coccyx  is 
normally  movable  and  is  displaced  backward  in  labor  ;  the  obstet- 
rical anteroposterior  diameter,  therefore,  is  measured  from  the 
tip  of  the  sacrum  to  the  lower  edge  of  the  symphysis  pubis  ;  it  is 
II  cm.  (4.33  in.).  The  transverse  diameter,  measured  from  one 
to  the  other  tuberosity  of  the  ischium,  is  11  cm.  (4.33  in.). 

Pelvic  Position. — By  pelvic  position  is  meant  the  angle  or 
inclination  of  the  pelvis  to  the  trunk  and  to  the  horizon.  The 
inclination  of  the  plane  of  the  superior  strait  to  the  horizon,  as  the 
individual  stands  erect,  is  fifty-five  degrees,  and  of  the  inferior  strait, 
ten  degrees.  The  inclination  of  the  pelvis,  however,  changes  with 
changes  of  posture.  It  disappears  in  a  squatting  or  sitting  posture, 
and  is  increased  if  the  individual  leans  backward.  The  greater 
the  inclination  of  the  pelvis,  the  more  the  axis  of  the  superior 
strait  diverges  from  the  long  axis  of  the  uterine  cavit}^,  and  con- 


THE  ANATOiMY  OF  THE  PELVIS. 


23 


Fig.  5. — The  inclination  of  the  pelvis. 

sequently  the  greater  must  be  the  divergence  in  direction  of  the 
presenting  part  from  that  of  the  rest  of  the  fetal  body  when  the 
former  engages  in  the  superior  strait.  Much  stress  was  once 
laid  upon  this  fact,  but,  by  placing  a  woman  upon  her  side  and 
flexing  the  thighs  upon  the  trunk,  the  inclination  of  the  pelvis 


Fig.  6. — Variation  in  sacral  cur\'es  :   /*,  Promontory  of  sacrum  ;    C,  coccyx.      (Trac- 
ings of  sacra  in  the  author's  possession.) 


24  PREGNANCY. 

is  made  practically  to  disappear.  The  obliquity  of  the  pelvis, 
therefore,  need  not  be  seriously  considered,  as  a  rule,  in 
labor,  but  the  habitual  inclination  of  the  pelvis  as  the  woman 
stands  erect  must  be  taken  into  account  in  a  study  of  the 
pelvic  deformities  of  rachitis,  lordosis,  kyphosis,  spondylolis- 
thesis, and  osteomalacia;  some  of  the  anomalies  of  labor  in 
these  pelvic  deformities;  and  the  abnormal  relations  of  the  ex- 
ternal genitalia  to  the  pelvis,  whenever  the  latter  shows  an 
excessive  or  deficient  inclination. 

Pelvic  Direction. — By  this  term  is  meant  the  direction  of  the 
central  axis  of  the  pelvic  canal.  It  was  the  custom  in  a  former 
generation  to  express  pelvic  direction  by  a  complicated  mathe- 
matical formula,  yielding  what  was  called  the  "curve  of  Cams." 
Not  only  is  this  formula  unnecessarily  comphcated,  but  it  is 
also  incorrect.  The  direction  of  the  pelvic  canal  depends  entirely 
upon  the  curve  of  the  sacrum,  which  varies  greatly.  Taking, 
at  random,  any  half-dozen  or  so  of  sacra  from  a  collection,  the 
utmost  diversity  of  curvature  is  seen.  The  direction  of  the  pelvis 
may  be  described  with  approximate  accuracy  as  a  line  parallel 
with  the  sacral  curve,  and  equally  distant  at  all  points  from  the 
pelvic  walls. 

The  Development  of  the  Pelvis. — It  may  be  easier  to  understand 
the  peculiarities  of  the  adult  pelvis  if  one  considers  the  forces 
imposed  upon  it  and  their  influence  upon  the  individual  bones 
and  upon  the  pelvis  as  a  whole.  The  pelvis  is  subjected  to  the 
weight  of  the  trunk  imposed  upon  it  from  above,  the  counter- 
pressure  of  the  limbs  below,  and  the  pull  of  powerful  ligaments, 
muscles,  and  joints.  The  weight  of  the  trunk,  transmitted  from 
above  downward  and  from  behind  forward,  tilts  the  pelvis  forward 
by  a  rotary  movement  on  its  transverse  axis  and  confers  upon  it 
the  characteristic  position  or  inclination.  This  force,  however, 
is  resisted  by  the  pull  of  the  muscular  and  ligamentous  con- 
nections between  the  trochanters  of  the  femora  and  the  tuber- 
osities of  the  ischia  and  by  the  pressure  of  the  heads  of  the 
femora  on  the  acetabula.  By  the  former  force  the  tuberosities 
of  the  ischia  are  pulled  apart  and  the  normal  width  of  the  pelvic 
outlet  is  secured.  The  sacrum  bears  the  greatest  weight  of  the 
trunk,  and  in  consequence  its  top  is  forced  downward  and  for- 
ward. It  is  also  pulled  forward  and  downward,  even  in  fetal 
life,  by  the  extension  of  the  thighs.  The  natural  consequence 
would  be  to  tilt  the  lower  end  of  the  sacrum  and  the  coccyx  back- 
ward, but  they  are  subjected  to  the  powerful  pull  forward  of  the 
ligaments  and  muscles  attached  to  them  and  to  the  lateral  and  ante- 
rior pelvic  walls.  Hence  the  sacrum,  subjected  to  these  two  oppos- 
ing forces,  is  bent  Hke  a  bow  between  them,  and  thus  acquires  its 
perpendicular  curve.     As  the  upper  portion  of  the  sacrum  moves 


THE  ANATOMY  OF   THE   PELVIS. 


25 


downward  and  forward,  it  drags  with  it  the  posterior  superior  por- 
tions of  the  iliac  bones,  to  which  it  is  attached  by  the  sacro-iliac 
junctions  and  by  the  strong  sacro-iUac  Hgaments.  The  natural 
result  of  the  rnovement  of  the  posterior  portions  of  the  in- 
nominate bones  inward,  downward,  and  forward  would  be  to 
throw  outward  the  anterior  extremities  of  these  bones,  were 
they  not  joined  firmly  at  the  symphysis.  Subjected  to  the 
force  behind  and  restrained  by  their  junction  in  front,  the  innomi- 
nate bones  are  bent  upon  themselves,  and  thus  acquire  their 
lateral  curve. 

These  few  illustrations  by  no  means  exhaust  the  dynamics  of 
the  pelvis.  The  subject  will  be  referred  to  again  in  the  study  of 
some  of  the  pelvic  deformities. 

The  Bony  Pelvis  in  Life  Filled  with  Soft  Tissues. — Besides 
the  generative  organs,  the  obstetrical  anatomy  of  the  pelvis  must 


Fig.  7. — The  pull  of  the  ligaments  and  the  pressure  uf  the  femora  upon  the  jielvis 

(Schroeder). 


take    into    account    the     muscles,   ligaments,   connective   tissue, 
blood-vessels,  lymphatics,  and  nerves. 


26 


PREGNANCY. 


The  Muscles. — The  iliopsoas,  the  obturator  internus,  and  .the 
pyriformis  clothe  the  pelvic  walls,  modifying  the  diameters  of 
the  pelvic  cavity  and  acting  as  buffers  or  cushions  to  protect  the 
child's  body  in  its  passage  through  the  birth-canal.  The  bulky 
iliopsoas  muscles  diminish  the  transverse  diameter  of  the  pelvic 
inlet  by  5  cm.  (2  in.),  thus  making  the  oblique  diameters  of  the 
pelvic  inlet  the  longest  and  insuringordinarily  an  oblique  position 
of  the  presenting  part,  but  these  muscles  are  subject  to  compres- 
sion and  to  some  displacement  under  pressure  in  labor,  and,  if 
the  pressure  is  great,  the  transverse  diameter  again  becomes 
the  longest ;  hence  the  transverse  position  of  the  head  in  ob- 
structed labors.  The  coccygeus,  the  levator  ani,  the  retractor  ani, 
the  sphincter  ani,  the  constrictor  vaginae,  and  the  transversus 
perinei  are  the  muscles  of  the  pelvic  floor  giving  the  direction  to 


Fig.  8. — The  pelvis  with  its  soft  parts  (bladder,  rectum,  uterus  and  its  appendages, 
having  been  removed)  (from  a  model  in  the  University  of  Pennsylvania). 

the  lower  part  of  the  parturient  tract  in  labor  and  directing  the 
presenting  part  forward,  outward,  and  upward  under  the  pubic 
arch.     The  levator  ani  is  by  far  the  most  important  muscle  in  the 


PLATE    g. 


(li    — 


THE  ANATOMY  OF   THE   PELVIS. 


V 


pelvic  floor.  It  is  a  strong,  horseshoe-shaped  band  of  muscle, 
consisting  of  two  symmetrical  halves  slung  back  from  the  anterior 
pelvic  wall  and  surrounding  the  vagina  and  rectum.  It  is  the 
chief  factor  in  pushing  the  presenting  part  forward  away  from  the 
perineum  and  out  through  the  vulvar  orifice.  It  is  thus  the  chief 
conservator  of  the  integrity  of  the  pelvic  floor  in  labor.  Its  injury 
robs  the  rectum  and  posterior  vaginal  wall  of  their  strongest  sup- 
port, allowing  them  to  drop  downward,  outward,  and  forward  in 
the  rectocele,  with  which  the  surgeon  has  to  deal  in  secondary 
operations  upon  so-called  lacerations  of  the  perineum. 


Fig-  9- — The  pelvic  canal  encroached  upon  by  the  soft  structures  (Veil). 


The  ligamentous  structures  of  the  pelvis  of  greatest  interest  to 
the  obstetrician  are  the  obturator  membranes  and  the  sacrosciatic 
ligaments,  which  close  the  pelvic  walls,  help  to  impart  to  the 
canal  its  shape  and  direction,  and,  by  their  situation  at  either  end 


28 


PREGNANCY. 


of  the  oblique  diameters,  receive  upon  their  yielding  surfaces  the 
greatest  pressure  from  the  extremities  of  the  long  diameters  of 
the  fetal  head, — an  arrangement  much  more  favorable  for  the  child 
than  would  be  the  compression  of  the  longest  diameters  of  the 
head  between  bony  pelvic  walls. 

The  Connective  Tissue  of  the  Pelvis. — An  intimate  knowledge 
of  the  complex  arrangement  of  the  pelvic  fascia  is  not  essential 


Fig.  lo. — The  pelvic  diaphragm  from  above  :  a,  Ischio-coccygeus  muscle ; 
b,  iliac  portion  of  the  levator  ani ;  c,  pubic  portion  of  the  levator  ani ;  d,  arcus 
tendineus  (Bumm). 

to  the  obstetrician.  For  his  purpose  it  suffices  to  remember  that 
the  arrangement  of  the  pelvic  connective  tissue  may  be  compared, 
roughly  speaking,  to  a  six-pointed  star  centering  at  the  uterus, 
the  three  arms  on  each  side  being  disposed  as  follows  :    A  lateral 


Fig.  II. — The  pelvic  diaphragm,  seen  from  below:  ^7,  Lschio-toccygeus ; 
b,  iliac  portion  of  levator  ani  ;  c,  pubic  portion  of  levator  ani  ;  </,  urogenital  dia- 
phragm, including  muscle  of  the  urogenital  trigonum  (Bumm). 

arm  running  out  from  the  uterus  between  the  layers  of  the  broad 
ligament  and  becoming  continuous  with  the  subperitoneal  connect- 


THE  ANATOMY  OF   THE   PELVIS. 


29 


Fig.  12. — Schematic  representation  of  the  superior  strait:  a.  Promontory; 
b,  symphysis;  I,  I,  iliopsoas  muscles;  2,  2,  rectus  abdominis;  dotted  line,  the 
pelvic  inlet  (Veil). 

ive  tissue  of  the  lateral  pelvic  wall;  an  anterior  arm  skirting  the 
bladder;  a  posterior  arm  skirting  the  rectum  and  continuing  in 


Fig.  13. — The  plane  of  pelvic  expansion:  a,  Sacrum;  l\  pubis;  c,  lateral 
pelvic  wall ;  I,  I,  pyriformis ;  2,  2,  obturator  internus  ;  w,  w,  obturator  membrane; 
i,  i,  sciatic  nerve. 


30 


PREGNANCY. 


Fig.   14.— Plane  of  pelvic  contraction:   a,  Tip  of  sacrum;  b,  b,  ascending  ramus  of 
pubis  ;   c,  c,  ischium  ;    I,  I,  obturator  internus. 


Fig.  15. — Female  pelvis,  viewed  from  above,  with  ligaments  (one-third 
natural  size)  (Dickinson). 


THE   ANATOMY  OF  THE   PELVIS. 


31 


Fig.    16. — Sacrosciatic  ligaments. 


Fig.  17. — The  pelvic  ligaments  from  above:  a.  Tip  of  sacrum;  b,  subpubic 
ligament ;  r,  tuber  ischii ;  d,  sacrosciatic  notch  ;  e,  aperture  for  femoral  vessels  and 
nerves  ;   h,  Poupart's  ligament  (Hart). 


Fig.  18. — The  pelvic  ligaments  from  below.      Lettering  same  as  above,  except 
X,  sacrosciatic  foramen. 


32  PREGNANCY. 

the  mesorectum  to  the  posterior  pelvic  wall.  Branching  pro- 
cesses, in  addition,  follow  the  round  ligament  to  the  groin  and 
mons  veneris,  the  vessels  and  nerves  escaping  through  the  sacro- 
sciatic  notch  to  the  buttocks,  the  three  canals  of  the  pelvis — 
the  urethra,  vagina,  and  rectum — to  the  subcutaneous  connec- 
tive tissue  of  the  external  genitalia  and  perineum. 

The  BIood=vesseIs. — The  ovarian  arteries,  leaving  the  aorta, 
enter  the  pelvis  on  their  respective  sides  and,  passing  between  the 
laminae  of  the  broad  ligament  a  short  distance  under  its  upper 
edge,  send  branches  to  the  ovaries  and  tubes  and  a  branch  to  the 
fundus,  while  the  main  trunk  turns  at  a  right  angle  downward 
alongside  the  uterus,  to  anastomose  with  the  uterine  artery,  giv- 
ing off  on  its  way  numerous  branches  to  the  uterine  wall.  The 
uterine  artery  on  both  sides  passes  downward  from  the  anterior 
trunk  of  the  internal  iliac  to  the  neck  of  the  uterus,  giving  off  a 
large  branch  to  the  lower  uterine  segment  and  cervix,  the  circu- 
lar artery  of  the  cervix,  and  numerous  smaller  branches  to  the 
uterine  wall  as  it  rises  to  meet  the  ovarian  artery.  The  veins  of 
the  pelvic  organs  of  chief  interest  to  the  obstetrician  are  the  large 
trunks  between  the  layers  of  the  broad  ligament  alongside  the 
uterus  and  the  complicated  pampiniform  plexuses  in  the  neigh- 
borhood of  the  ovaries. 

The  lymphatic  ducts  of  the  pelvic  organs  are  of  interest  mainly 
in  the  part  they  play  in  the  absorption  of  the  involuting  uterus 
and  by  conveying  septic  micro-organisms  and  the  products  of 
their  activity  into  the  system.  The  lymph-spaces  of  the  uterus, 
lying  between  connective-tissue  bundles  and  clothed  with  endo- 
thelial cells,  empty  by  means  of  ducts  into  the  pelvic  system  of 
lymphatic  glands.  The  most  important  groups  of  the  pelvic 
lymphatic  glands  are  the  uterine,  obturator,  hypogastric,  lumbar, 
sacral,  and  inguinal.  It  is  interesting  to  note  that  the  lymphatic 
ducts  of  the  lower  fourth  of  the  vagina  terminate  in  the  inguinal 
glands.  The  enlargement,  inflammation,  and  suppuration  of  the 
inguinal  glands,  therefore,  indicate  infection  of  the  parturient  outlet. 

The  nerves  of  the  generative  organs  are  derived  from  the 
spinal  and  the  sympathetic  systems.  The  sexual  processes, 
however,  of  ovulation  and  of  menstruation  and  the  action  of  the 
uterine  muscle  in  labor  are  controlled  by  the  sympathetic  nerves, 
derived  mainly  from  the  hypogastric  and  ovarian  plexuses.  The 
clinical  observation  that  paralysis  of  the  spinal  nerves  supplying 
the  pelvic  organs  in  nowise  interferes  with  gestation  and  labor, 
and  the  experiments  on  bitches  of  resecting  the  lumbar  cord  and 
seeing  the  animals  exhibit  rut,  become  gravid,  and  bear  pups, 
show  what  a  subordinate  part  the  spinal  nerves  play  in  the  sexual 
processes  of  the  female. 


THE  ANATOMY  OF   THE   PELVIS. 


33 


Fig.  19. — The  arteries  of  the  uterus  and  ovaries  :  O.A.,  Ovarian  artery ;  i>,  artery 
of  the  round  ligament ;  y,  branch  to  the  tube  ;  c,  c,  c,  branches  to  the  ovary ; 
d,  continuation  of  main  trunk  ;  e,  branch  to  the  cornu ;  U.A.,  uterine  artery  ;  e,  main 
trunk ;  f,  bifurcation ;  g,  vaginal  branches ;  h,  vaginal  branch  from  the  cervical 
artery  (Hyrtl). 


Fig.  20. — The  veins  of  the  uterus  (Hyrtl). 


34 


PREGNANCY. 


Fig.  21. — Distribution  of  lymphatics,  externally:  b,  Inguinal  glands;  c,d,  ducts  of 
the  labia;   e,  lymphatics  of  the  mons  veneris  (Sappey). 


Fig.  22. — The  lymphatic  ducts  of  the  uterus  and  its  appendages  injected,  in  a  woman 
who  died  shortly  after  delivery. 


THE  ANATOMY  OF   THE  PELVIS. 


35 


Fig.  23. — Lymphatics  of  the  pelvic  viscera  and  abdomen  :  A,  Aorta  ;  B,  B,  iliac 
arteries ;  C,  C,  the  bifurcation  and  two  branches  of  the  iliac  arteries ;  D,  vena  cava ; 
E,  left  renal  vein;  F,  right  renal  vein;  G,  iliac  veins;  H,  H,  ureters;  I,  rectum; 
K,  uterus;  L,  cervix;  M,  M,  vaginal  walls  ;  N,  N,  Fallopian  tubes  ;  F,  P,  ovaries; 
Q,  Q,  round  ligaments  ;  i,  Deep  lymphatic  vessels  of  the  right  kidney,  and  ganglia 
into  which  they  empty ;  2,  2,  2,  2,  superficial  lymphatic  vessels  ;  3,  3,  3,  3,  the  same  ; 
4,  two  ganglia  that  receive  these  superficial  vessels ;  7,  7,  subovarian  plexus  of 
lymphatics  ;  8,  8,  ducts  leading  from  this  plexus  ;  9,  9,  the  same  ;  10,  lo,  11,  11,  glands 
receiving  these  ducts  ;  12,  12,  12,  12,  lymphatic  ducts,  originating  in  the  fundus  uteri, 
and  terminating  in  the  same  glands  as  the  ovarian  ducts;  13,13,  ducts  from  the 
anterior  surface  and  sides  of  the  uterus  ;  14,  I4,  glands  into  which  they  empty ; 
15,  15,  ducts  originating  in  cervix  and  upper  part  of  vagina  ;  16,  16,  glands  into 
which  they  empty;  17,  17,  efferent  vessels  of  these  glands;  18,  18,  lymphatic  ducts 
from  posterior  surface  of  the  uterus  and  glands  into  which  they  empty  ;  19,  lumbar 
gland  (exceptional)  ;  20,  gland  into  which  occasionally  a  duct  from  lower  uterine 
segment  empties  (Sappey). 


36 


PREGNANCY. 


Fig.  24. — The  nerves  of  the  pelvis:  A,  Abdominal  aorta;  B,  lumbar  vertebrae 
with  intervertebral  discs  ;  C,  the  right  portion  of  the  sacrum  sawn  after  removal  of  os 
innominatum  ;  D,  ureter;  E,  pyriformis  muscle  cut  at  its  exit  from  the  pelvic  cavity; 
F,  the  curve  of  the  rectum,  corresponding  to  the  anterior  surface  of  the  sacrum  ;  H, 
virginal  uterus  feebly  developed ;  K,  right  ovary  displaced  somewhat  upward ;  L, 
bladder ;  M,  levator  ani  muscle,  cut  in  part ;  N,  ischiocavernosus  muscle  ;  O,  corpus 
cavernosum  clitoridis,  joining  on  the  other  side  the  clitoris,  covered  with  nerve-fila- 
ments ;  P,  symphysis  pubis  (the  whole  body  being  inclined  forward,  it  has  become  hori- 
zontal); T,  fimbriated  end  of  Fallopian  tube  ;  I,  I,  Lumbarnen'es ,  passing  out  of  the 
intervertebral  foramina  to  form  the  htmbarp/exus;  the  lower  lumbar  and  the  upper  sacral 
nerves  joining  to  form  the  sacral  plexus  in  front  of  the  pyriformis  muscle;  2,  sacral 
plexus ;  3,  gluteal netiies  cut ;  ihe pudic  nerve  springing  by  several  roots  from  the  plexus 


THE   ANATOMY  OF  THE   PELVIS. 


17 


Fig.  25. — Pelvic  nerves  of  a  puerpera  four  days  postpartum. 

formed  by  the  lower  sacral  nerves;  5,  fine  twigs  passing  from  the  pudic  nerve  to  the 
ischiocavernosus  muscle  ;  the  main  trunk  goes  under  the  symphysis,  and  ends  as  the 
dorsal  nerve  of  the  clitoris  (21);  6,  6,  branches  of  communication  which  carry  sympathe- 
tic twigs  to  the  spinal  nerves  and  spinal  twigs  to  the  hypogastric  jilexus  of  the  sympathe- 
tic; 7)  principal  trunk  of  the  jri'w/tf/'/^d'/'/t' in  front  of  the  lumbar  vertebrce;  S,  continuation 
of  the  sympathetic  in  front  of  the  sacrum;  9,  9,  aortic  plexus :  lO,  hemorrhoidal  plexus, 
following  the  arteries  of  the  same  name  ;  II,  superior  hyfoi^astric  plexus,  ov  iliohvpo- 
gastric  plexus,  which  receives  many  spinal  and  sympathetic  branches;  \7.,  inferior 
hypoa^astric  plexus,  communicating  with  I3,  anterior  sacral  plexus,  made  up  of  spinal 
and  sympathetic  branches  ;  14,  from  the  many  ganglia  placed  in  this  plexus  it  has  a 
network  appearance  ;  15,  inferior  rectal  twigs,  which  jiassdown  even  to  the  sphincter, 
where  they  form  a  network  covered  by  the  levator  ani  ;  16,  Tat^'-iual plexus ;  17,  that 
part  of  the  inferior  hypogastric  plexus  in  the  shape  of  a  fine  network  at  the  upper  end 
of  the  vagina  gives  branches  to  the  bladder,  the  Fallopian  tube,  and  the  clitoris;  18, 
nerve  twigs  which  run  on  the  side  wall  of  the  uterus,  giving  branches  to  it,  upward 
to  the  Fallopian  tube  and  ovary,  where  they  join  the  nerves  following  the  ovarian 
artery,  which  correspond  to  the  spermatic  plexus  in  man;  19,  vesical  nerves;  20, 
t4terine  plexus ;  21,  dorsal  veii'e  of  clitoiis,  which  joins  with  the  cavernous  plexus 
of  the  clitoris  from  the  sympathetic  to  the  glans  clitoridis  (Rydygier). 


38 


PREGNANCY. 


Fig.  26. — Nerves  of  the  pelvic  organs  of  the  female:  i,  Nerves  to  fundus  of 
uterus ;  2,  right  Fallopian  tube  ;  3,  right  round  ligament ;  4,  nerves  to  Fallopian 
tube;  5,  communication  between  ovarian  and  uterine  nerves;  6,  ovarian  plexus 
of  veins;  7,  ovarian  vein;  8,  nerve  passing  to  join  ovarian  plexus;  9,  fimbri- 
ated extremity  of  Fallopian  tube ;  10,  reflected  peritoneum  ;  1 1,  uterine  nerves ;  12, 
superior  hypogastric  plexus;  13,  branches  from  hypogastric  plexus  to  uterus;  14, 
inferior  hypogastric  plexus  ;  15,  vesical  nerves  ;  16,  communicating  branches  to  vesical 
plexus ;  17,  cervical  ganglion  ;  18,  branches  of  hypogastric  plexus  to  cervical  ganglion  ; 
19,  first  sacral  nerve  ;  20,  branches  passing  to  bladder  ;  21,  branches  passing  between 
bladder  and  rectum ;  22,  communicating  branches  from  second  sacral  to  cervical 
ganglion ;  23,  branch  from  third  sacral  nerve  to  cervical  ganglion  ;  24,  second  sacral 
nerve;  25,  branches  from  third  sacral  nerve  to  vagina  and  bladder;  26,  branches 
passing  from  fourth  sacral  to  cervical  ganglion  (Frankenhausen). 


THE  FEMALE   SEXUAL    ORGANS. 


39 


THE  FEMALE  SEXUAL  ORGANS. 

The  development  of  the  sexual  organs  may  be  briefly  de- 
scribed as  follows  : 

The  development  of  the  genito-urinary  organs  up  to  a  certain 
point  is  common  in  both  sexes.  In  late  stages  the  duct  of  Wolff 
almost  disappears  in  the  female,  while  in  the  male  it  constitutes  the 
vas  deferens  ;  the  Miillerian  ducts,  on  the  contrary,  atrophy  in  the 
male,  but  form  Fallopian  tubes,  uterus,  and  vagina  in  the  female. 

The  accompanying  illustrations  (Figs.  27,  28,  29,  and  30) 
may  aid  the  student  to  understand  the  subdivision  of  the  primary^ 
cloacal  chamber.  As  they  refer  to  the  female  embryo,  the 
Wolffian  ducts  are  omitted. 


Fig.  27. 


Fig.  28. 


Fig.  29. 


Fig-  30. 


Fig.  27. — ;:/,  Cloaca  which  has  opened  into  primitive  hind-gut,  and  commu- 
nicates with  the  rectum  and  allantois ;  the  posterior  portion,  all,  of  the  latter  has 
commenced  to  dilate  to  form  the  urinary  bladder ;  w,  duct  of  Miiller  ;   r,  rectum. 

Fig.  28. — The  cloaca  has  divided  into  a  ventral  portion,  sii,  the  urogenital 
sinus,  which  communicates  ventrally  with  the  urethra,  //,  and  the  bladder,  b,  and 
more  dorsally  with  v,  the  vagina,  formed  by  fusion  of  the  ducts  of  Miiller;  r,  rectum. 

Fig.  29. — The  perineum  or  tissues  separating  the  rectum  from  the  urogenital 
sinus  are  well  developed  ;  the  neck  of  the  bladder  has  become  constricted  to  form  the 
primitive  urethra,  and  is  separated  from  the  vaginal  passage,  though  both  open  into 
the  common  urogenital  sinus,  s,  and  the  clitoris,  c  (in  the  male  the  rudiment  of  the 
penis),  has  appeared;   r,  rectum. 

Fig.  30. — The  urogenital  sinus  of  the  female,  s,  remains  as  the  cleft  between  the 
sides  of  the  external  aperture  of  the  labia  minora  ;  it  communicates  in  front  with  the 
bladder,  b,  and  dorsally  with  the  vagina,  v ;  r,  rectum. 


The  essential  sexual  glands  develop  in  both  sexes  in  close 
association  with  the  ducts  of  Wolff  and  Miiller,  and  in  the  neigh- 
borhood of  the  mesonephros.  The  cells  lining  the  abdominal 
region  of  the  primitive  celom  early  become  differentiated  as  its 
lining  epithelium  ;  in  most  regions  they  quickly  become  flat 
scales,  but  over  the  bulging  of  the  intermediate  cell-mass  they 
enlarge  and  become  columnar  in  form.  These  enlarged  cells 
remain  for  some  time  over  all  of  the  projecting  surface  of  the 
intermediate  cell-mass,  and  even  extend  beyond  it  upon  the  outer 
side  of  the  developing  mesentery.  They  soon  become  flattened 
over  most  of  the  mass,  but  remain  columnar  and  multiply  for 
some  time  on  its  inner  and  outer  sides.      On  the  latter  they  give 


40 


PREGNANCY. 


origin  to  the  Miillerian  duct  and  some  segmental  tubes  and  soon 
cease  to  be  distinct  ;  on  the  former  they  constitute  the  primi- 
tive germinal  epithelium.  The  mesoblast  lying  beneath  this 
epithelium  gives  rise  to  the  blood-vessels  and  connective  tissue 
(stroma)  of  the  ovary  or  testis,  as  the  case  may  be.  At  this 
stage  it  is  difficult  or  impossible  to  detect  the  sex  of  the  em- 
bryo from  the  structure  of  the  sexual  glands. 

In  the  female  some  cells  of  the  germinal  epithelium  enlarge  to 
form  the  primitive  ova.  Surrounded  by  other  cells  from  the  germi- 
nal epithelium,  they  grow  into  the  ovarian  stroma  as  the  egg-tubes 
or  cords  and  give  rise  to  the  primitive  Graafian  follicles. 


Fig-  31- — Diagrams  to  illustrate  the  development  of  the  internal  genital  organs 
in  both  sexes.  I,  Hermaphrodite  or  undifferentiated  condition  :  d.  Ovary  or  testis, 
lying  upon  the  tubules  of  the  Wolffian  body ;  W,  Wolffian  duct ;  M,  duct  of  Miiller ; 
S,  urogenital  sinus.  2,  Modifications  in  the  female  :  T,  Primitive  INIiillerian  duct, 
forming  the  Fallopian  tube  and  developing  fimbriae,  F,  around  its  peritoneal  opening ; 
h' ,  ovarian  hydatid  ;  U,  uterus  formed  by  fusion  of  the  posterior  ends  of  the  ducts  of 
Miiller;  S,  urogenital  sinus;  O  (answering  to  D  in  I),  ovary;  P,  parovarium,  or 
remnant  of  Wolffian  body  and  duct.  3,  Modifications  in  the  male  :  H,  Testis 
(corresponding  to  Z)  in  I)  ;  E,  epididymis ;  h,  hydatid  of  Morgagni  ;  a,  vas  aberrans  ; 
V,  vas  deferens,  or  Wolffian  duct;  u,  uterus  masculinus,  the  remnant  of  the  lower 
ends  of  the  fused  ducts  of  Miiller  ;   .S",  urogenital  sinus  (from  Landois  and  Stirling). 


The  testicle  is  distinguishable  from  the  fetal  ovary  about  the 
eighth  week.  The  cells  which  in  the  female  form  ova,  in  the 
male  subdivide  and  give  origin  to  the  spermatozoa,  while  the 
cells  which  correspond  to  the  lining  cells  of  the  female  egg-tubes 
develop  the  lining  cells  of  the  seminiferous  tubules.  These 
canals  may  be  detected  in  the  human  embryo  of  ten  weeks  ;  they 
branch,  and  during  the  third  month  are  collected  into  groups, 
indicating  the  lobular  subdivision  of  the  adult  testis. 

The  genital  cord  is  a  cylindrical  mass  in  which,  in  both  sexes, 
the  ducts  of  Miiller  and  Wolff  become  imbedded  near  the  uro- 
genital sinus.      The  four  ducts  (two  from  each  side)  are  at  first 


THE   FEMALE   SEXUAL    ORGANS. 


41 


separate.  The  Miillerian  ducts  coalesce  at  their  lower  ends  and 
in  the  female  enlarge  to  form  the  vagina  and  the  posterior  por- 
tion of  the  uterus  ;  in  the  male  the  lower  fused  portions  of  Miil- 
lerian ducts  remain  as  the  prostatic  vesicle,  or  uterus  masculinus. 


Fig.  32. — Diagrammatic  outline  of  thie  Wolffian  bodies  and  their  relation  to 
the  ducts  of  Miiller  and  the  reproductive  glands  :  ot,  Seat  of  origin  of  ovary  or  testes  ; 
w,  Wolffian  body  ;  tv.  Wolffian  duct ;  m,  m,  duct  of  Miiller ;  gc,  genital  cord  ; 
ug,  urogenital  sinus;  i,  rectum;  d,  cloaca  (from  Allen  Thompson). 


Fhtibria. 


Bartholin' s 
gland. 

Fig.  33. — Diagram  illustrating  changes  taking  place  in  development  of  female 
generative  organs  (modified  from  Allen  Thompson). 

In  the  female  the  anterior  portions  of  the  ducts  of  Miiller 
form  the  upper  part  of  the  body  of  the  womb  and  the  Fallopian 
tubes.  In  the  female  the  Wolffian  ducts  almo.st  entirely  disap- 
pear, but  traces  of  them  may  be  found  as   the  canals  of  Gartner. 


42 


PREGNANCY. 


Pathological  development  and  distention  of  these  ducts  some- 
times give  rise  to  vaginal  cysts,  which  may  obstruct  labor. 

Meanwhile  most  of  the  Wolffian  body  (mesonephros)  disap- 
pears on  each  side,  but  remnants  of  it  may  be  found  in  adults. 
In  the  female  they  constitute  the  parovarium  (epoophoron,  or 
body  of  Rosenmiiller). 

The  Development  of  the  External  Genitals. — The  forma- 
tion of  the  cloaca  is  common  to  both  sexes,  as  is  also  its  separa- 
tion into  an  anal  and  a  urogenital  portion.  The  urogenital  sinus 
is  at  first  narrow  and  deep,  but  soon  becomes  shallow,  and 
meanwhile  the  perineal  tissues  separate  it  more  and  more  from 
the  anus.  Before  the  subdivision  of  the  cloaca  a  genital  emi- 
nence appears  at  its  ventral  or  anterior  end  about  the  sixth 
week.      On  each  side  of  the  cloacal  slit  outgrowths  of  skin  and 


Fig.  34. — To  illustrate  the  development  of  the  human  external  genitals :  I.  h, 
Genital  eminence ;  ;■,  cloacal  aperture ;  s,  tail  or  coccyx  of  embryo.  2.  h.  Genital 
eminence;  r,  cloacal  opening;  iv,  commencement  of  labia  majora  or  scrotum,  accord- 
ing to  sex  ;  J,  embryonic  tail.  3.  Next  stage,  practically  permanent  in  the  female  ;  c. 
Genital  eminence  (clitoris);  /,  nymphae  ;  Z,  labia  majora;  a,  anus.  4.  Later  or 
male  condition  :  P,  Penis ;  R,  edges  of  embryonic  folds  enfolding  to  inclose  the 
penial  urethra  ;  S,  scrotum ;  a,  anus.  5  and  6  illustrate  the  descent  of  the  testicle 
(from  Landois  and  Stirling). 


subcutaneous  tissue  (Fig.  34,  i)  become  prominent.  At  the  eighth 
or  ninth  week  there  is  a  groove  in  the  under  (posterior)  side  of 
the  genital  eminence,  with  well-marked  side-walls  leading  back 
to  open  into  the  cloaca.  The  development  of  the  perineum 
divides  this  groove  (during  the  third  month)  transversely  into  a 
smaller  anal  opening  and  a  larger  urogenital.  This  condition 
is  but  slightly  modified  in  the  female.  The  genital  eminence 
in  that  sex  remains  small  and  constitutes  the  clitoris.  The  side 
walls  remain  separate  and  form  the  labia  minora,  while  the  cuta- 
neous folds  enlarge  and  become  the  labia  majora  (Fig.  34,  3). 
The  urogenital  sinus  is,  therefore,  permanent  in  woman,  and  forms 
the  vestibule,  which  has  in  front  of  it  the  clitoris,  and,  opening 


THE   FEMALE   SEXUAL    ORGANS. 


43 


into  it,  the  urethra  and  vagina.      The  skinfolds  remain  separate  in 
the  female  to  form  the  labia  majora.  ^ 

The  genital  organs  and  structures  of  woman  are  divided  into 
the  external  and  the  internal  genitalia.  The  former,  described 
often  as  the  genitalia,  pudendum,  or  vulva,  comprise  the  mons 
veneris,   the  labia  majora,  the  labia  minora,   the  vestibule,  with 


ANU5 


"o'^'^   C  « r(\' 


UiAGBA 


F'g-  35- — Diagram  of  the  genitalia  (Dickinson). 


the  urethral  orifice,  and  the  clitoris  ;  the  latter,  the  hymen,  the 
vagina,  the  uterus,  the  Fallopian  tubes,  and  the  ovaries. 

The  Mons  Veneris  and  the  Labia  Majora. — The  mons  veneris 
is  a  flat  protuberance  over  the  symphysis  pubis,  consisting  of 
fat  and  connective  tissue  covered  with  a  tough  skin  clothed  with 
coarse  hair.      In  females  the   upper  border  of  the  hairy  region 

^  The  description  of  the  development  of  the  sexual  organs  is  taken,  with  modifi- 
cations, from  Newell  Martin's  article  in  "  The  American  System  of  Obstetrics," 
edited  by  the  author. 


44 


PREGNANCY. 


is  a  horizontal  line  ;  in  males  the  hair  rises  in  a  triangular 
shape  to  a  point  upon  the  median  line  of  the  abdominal  wall. 
The  labia  majora  are  folds  of  skin  containing  fat,  connective 
tissue,  and  involuntary  muscle-fibers,  continuous  with  the  mons 
veneris  and  uniting  below  an  inch  in  front  of  the  anus.  They 
surround  the  urogenital  fissure.  Their  points  of  junction  above 
and  below  are  called  the  anterior  and  posterior  commissures. 
Just  within  the  latter  there  is  a  crescentic  transverse  fold  of  skin, 
called  the  fourchet.  The  region  between  the  fourchet  and  the 
posterior  commissure  is  the  fossa  navicularis. 

The  Labia  Minora,  or  Nymphse. — ^Just  below  the  anterior  com- 
missure of  the  labia  majora  the  nymphae  begin  on  each  side  as  two 
leaflets  of  delicate  skin  ;  one,  the  upper,  with  its  fellow  of  the  other 


Fig.  36. — Hypertrophied  nymphiie  (author's  case). 


side,  constituting  the  glgpuce  of  the  clitoris  ;  the  lower  leaflet, 
with  its  other  half,  forming  the  frenum  of  the  prepuce.  Uniting 
below  and  to  the  outer  side  of  the  clitoris,  the  nymphae  run 
downward  to  merge  into  the  labia  majora  at  about  their  middle  or 
lower  third.  The  labia  minora  are  often  asymmetrical.  They  lie 
apposed  to  each  other  in  the  middle  line,  completely  covered 
by  the  labia  majora.  They  vary  much  in  size.  In  some  races 
(Hottentots)  they  are  enormous,  projecting  far  beyond  the  labia 
majora.  As  an  exception  this  condition  is  sometimes  seen  in 
the  Caucasian  race.  The  skin  of  the  nymphae  is  in  a  transition 
stage  between  mucous  membrane  and  skin.  It  merges  on  its 
outer  side  into  the  delicate  skin  of  the  inner  surface  of  the  labia 
majora,  and  on  its  inner  side  into  the  mucous  membrane  of  the 


THE   FEMALE   SEXUAL    ORGANS.  45 

vestibule.  The  venous  spaces  and  the  unstriped  muscular  fibers 
in  the  nymphae  resemble  the  structure  of  erectile  tissue. 

The  vestibule  is  the  space  between  the  clitoris,  nymphae,  and 
vaginal  entrance.  It  is  pierced  in  its  mid-line  by  the  urethral 
orifice, — the  external  meatus.  The  bulbs  of  tJie  vestibule  are  two 
masses  of  venous  plexuses  about  an  inch  long,  lying  along  the 
sides  of  the  vestibule  below  the  clitoris  and  within  the  nymphae. 
They  are  the  homologues  of  the  corpora  spongiosa  in  the  male. 
In  sexual  excitement,  by  muscular  compression  of  their  efferent 
vessels,  they  become  turgid  and  erect. 

The  clitoris  has  the  structure  and  anatomical  features  of  the 
penis,  but  in  miniature,  and  modified  by  the  cleft  below,  the 
absence  of  the  urethra,  and  the  separation  of  the  spongy  bodies 
into  the  bulbs  of  the  vestibule.  The  cavernous  bodies  of  the 
clitoris  are  erectile.  The  glans  of  the  clitoris  is  surrounded  at 
its  base  by  sebaceous  follicles  secreting  a  smegma,  which  may  be 
confined  by  preputial  adhesions,  and  is  likely  to  cause  irritation 
by  its  decomposition. 

The  urethral  orifice  or  external  urinary  meatus  is  a  round, 
slit-like  or  star-shaped  opening  on  an  eminence,  usually  crescentic 
in  shape,  sometimes  with  two  lateral  labia,  occasionally  surrounded 
by  four  tubercles.  Directly  below  this  eminence  is  the  tubercle 
representing  the  end  of  the  anterior  column  of  the  vagina.  Just 
within  the  orifice  of  the  urethra  on  its  posterior  wall  are  two 
efferent  ducts  (Skene's),  12-20  mm.  long,  communicating  with 
small  groups  of  tubular  glands,  said  to  be  homologues  of  the  pros- 
tatic glands. 

Bartholin's  glands,  or  the  vulvovaginal  glands,  are  muco- 
serous,  racemose  glands  about  a  third  of  an  inch  in  diameter, 
lying  under  the  mucous  membrane  of  the  lateral  vaginal  walls 
and  emptying  by  long,  slender  ducts  below  the  vestibule  and  to 
either  side  of  the  vaginal  entrance. 

The  Hymen. — The  crescentic  septum,  occluding  usually  the 
posterior  portion  of  the  vaginal  entrance,  with  the  concavity  of 
its  opening  directed  upward,  but  presenting  often  an  annular, 
cribriform,  cordiform,  crenelated,  or  cleft  appearance,  is  a  fold  of 
mucous  membrane  reinforced  by  fibrous  tissue,  usually  ruptured 
with  ease,  but  occasionally  so  firm  and  unclastic  that  it  even 
resists  the  impact  of  the  descending  head  in  labor.  The  hymen 
is  usually  torn  at  the  first  coitus,  sometimes  by  gynecological 
examinations,  or  by  masturbation.  It  is  partially  destroyed  in 
labor,  the  remnants  persisting  as  isolated  protuberances  around 
the  vaginal  orifice, — the  carunculae  myrtiformes. 

The  Vagina. — The  vagina  is  a  musculomembranous  canal 
extending  from  the  hymen  to  the  base  of  the  vaginal  portion  of 


46  PREGNANCY. 

the  cervix  uteri.  The  posterior  wall  of  the  canal  is  about  9  cm. 
(3.5  in.)  long,  the  anter.ior  6^cm.  (2.5  in.).  The  axis  ofltEe 
canal  is  slightly  sigmoid  in  shape,  but  corresponds  quite  closely 
to  the  axis  of  the  pelvic  canal.  The  upper  portion  of  the  canal 
is  expanded  into  the  vaginal  vault,  the  recesses  being  particu- 
larly well  marked  anteriorly  and  posteriorly,  constituting  the 
anterior  and  posterior  fornices.  The  vagina,  therefore,  is  flask- 
shaped.  The  vaginal  walls  are  composed  of  three  structures, — 
the  mucous  membrane,  the  muscular  coat  in  tw^o  layers  (the 
inner  circular  and  the  outer  longitudinal),  and  a  fibrous  sheath. 
The  anterior  and  posterior  walls  should  be  in  contact,  while 
the  lateral  walls  are  thrown  into  folds  which  give  a  transverse 
section  of  the  vagina  the  shape  of  the  letter  H.  The  mucous 
membrane  is  covered  with  squamous  epithelium,  and  with 
numerous  papillae,  but  has  no  glands  except  a  few  tubular 
structures  in  the  upper  part  of  the  canal.  The  mucous  mem- 
brane i'S  thrown  into  numerous  transverse  folds  or  rugae,  most 
marked  upon  the  anterior  wall  and  in  nulliparous  women. 
There  is  an  anterior  and  a  posterior  cord-like  process  in  the 
median  line,  the  anterior  and  posterior  columns  of  the  vagina, 
indicating  the  lines  of  junction  of  the  ducts  of  Miiller. 

The  Uterus. — The  uterus  is  a  hollow,  muscular  organ,  in  the 
adult  virgin  measuring  7.5  cm.  (3  in.)  in  length,  4  cm.  (1.6  in.)  in 
breadth,  and  2. _5^  cm.  (rTnT)  in  its  anteroposterior  diameter.  In 
shape  the  uterus  is  a  flattened,  pyriform  body,  the  anterior  wall  be- 
ing almost  perfectly  flat,  the  posterior  more  convex.  It  is  divided 
into  the  body,  the  isthmus,  and  the  neck,  or  cervix.  The  first 
occupies  about  three-fifths  of  its  length,  the  last,  two-fifths.  In 
structure  the  uterus  consists  of  a  muscular  wall  with  a  mucous 
lining  and  a  peritoneal  covering.  The  muscle  is  unstriated  and 
is  arranged,  roughly  speaking,  in  three  layers, — an  external,  a 
middle,  and  an  internal.  The  middle  layer  constitutes  the  bulk 
of  the  wall ;  its  fibers  are  arranged  in  a  somewhat  spiral  form, 
though  no  very  definite  arrangement  is  to  be  distinguished.  The 
fibers  of  the  inner  and  outer  layers  are  arranged  in  longitudinal 
and  circular  bands.  The  mucous  membrane  of  the  body  of  the 
uterus  is  composed  of  columnar,  ciliated,  epithelial  cells,  resting 
upon  a  delicate  basement  membrane.  The  cilia  of  the  uterine 
epithelium  lash  in  the  same  direction  as  those  of  the  tubes, 
namely,  from  within  outward,  or  from  above  downward.  ^  As 
there  is  no  submucous  tissue,  the  mucosa  of  the  uterus  rests  di- 
rectly upon  the  muscle.  The  uterine  mucous  membrane  is 
richly  supplied  with  tubular  glands,  divided  in  their  lower  ends 

^  This  has  long  been  a  disputed  point.  See  Mandl.  "  Ueber  die  Richtung  der 
Flimmerbewegung  im  menschlicben  Uterus,"     "  Centralbl.  f.  Gyn.,"  No.  13,  1898. 


THE   FEMALE   SEXUAL    ORGANS. 


A7 


usually  into  two  branches  or  forks.  In  the  cervix  the  mucous 
membrane  is  thrown  into  longitudinal  folds  with  lateral  branches, 
— the  arbor  vit^e  of  the  uterus.  The  epithelial  cells  in  the  upper 
two-thirds  of  the  cervdcal  canal  are  columnar,  ciliated,  in  the 
lower  third  stratified,  squamous  cells.  In  addition  to  the  tubu- 
lar glands  of  the  uterine  body  the  cervical  mucous  membrane 
contains  wide  mucous  crypts,  the  orifices  of  Avhich  easily  become 
obstructed,  so  that  they  are  converted  into  retention  cysts,  which 
commonly  stud  the  cer\^ix  in  cases  of  old  inflammation  or  in- 
jury,— the  glands  or  follicles  of  Naboth. 


F'g-  37- — Perpendicular  section  through  normal  uterine  mucous  membrane ;  showing 
glands  and  interstitial  tissue  (Uoderlein). 

The  uterine  cavity  is  normally  fusiform,  widened  in  its  upper 
part  into  a  triangular  space,  most  contracted  below  at  the  level 
of  the  internal  os  uteri.  It  has  three  openings,  the  internal 
OS  communicating  with  the  cervical  canal  and  the  two  uterine 
orifices  of  the  Fallopian  tubes.  The  cervical  canal  in  the  nul- 
liparous  woman  is  a  slender  ovoid  in  shape,  contracted  at  its 
upper  and  lower  boundaries, — the  internal  and  the  external  os 
uteri.      In  a  woman  who  has  borne  children  the  cervical  canal  is 


48 


PREGNANCY. 


often  funnel-shaped,  the  external  os,  or  the  cavity  just  above  it, 
being  the  most  expanded  portion. 

The  cervix  itself  is  divided  into  two  portions,  the  vaginal  and 
the  supravaginal.     The  former  projects  into  the  vaginal  vault; 


^1 


^  lNTE1\MEtfS 
/^  POHTIOfi 

^/  / 

VflCINAL/ 
PoRTIOlJJf 


Fig.  38. — Diagram  illustrating  the  relations  of  the  uterus  to  the  vagina,  bladder, 
and  peritoneum  (Dickinson). 


Fig-  39. ^Uterus  didelphys  :  a,  Right  segment ;  b,  left  segment ;  c,  d,  right  ovary 
and  round  ligament ;  /,  e,  left  ovary  and  round  ligament ;  g,  j,  left  cervix  and  va- 
gina ;  k,  vaginal  septum  ;  h,  i,  right  cervix  and  vagina. 

the  latter  is  attached  to  the  vaginal  walls  and  extends  a  short 
distance  above  their  attachments.  The  anatomist  commonly 
speaks  of  the  supravaginal  portion  as  being  entirely  above  the 


THE  FEMALE   SEXUAL    ORGANS. 


49 


vaginal  attachments  and  extending  to  the  isthmus.  This  view, 
however,  is  erroneous,  as  it  assumes  that  the  lower  uterine  seg- 
ment is  a  part  of  the  cervix. 

It  is  usual  to  describe  an  anterior,  shorter  lip  of  the  cervix  and 
a  longer  posterior  one.  This  description  is  more  accurate  in  the 
parous  woman  with  a  bilateral  tear  of  the  cervix.  As  may  be 
seen  in  figure  38,  the  supravaginal  portion  of  the  cervix  is  longer 
anteriorly  than  posteriorly.      The  normal  position  of  the  uterus 


Fig.  40. — Uterus  bicornis  duplex:  a,  a,  Double  entrance  to  vagina;  b,  meatus 
urinarius  ;  c,  clitoris  ;  d,  urethra  ;  e,  e,  double  vagina  ;  /,  /,  external  orifices  of  uterus  ; 
g,  g,  double  cervix;  h,  h,  bodies  and  horns  of  uterus;  i,  i,  ovaries;  k,  k,  tubes; 
/,  /,  round  ligaments  ;   w,  m,  broad  ligaments. 

is  almost  horizontal  as  the  woman  stands  erect.  It  is  slung 
between  the  layers  of  the  broad  ligament,  supported  by  lateral, 
anterior,  and  posterior  musculofibrous  bands  and  folds  of  peri- 
toneum. It  is  so  freely  mobile  tha*  it  rises  and  falls  with  every 
breath  the  woman  draws. 

The  uterus  is  formed  by  the  junction  and  fusion  of  the  two 
ducts  of  Muller.     An  arrest  of  development  in  embryonal  life 
4 


50 


PREGNANCY. 


results  in  a  partial  junction  or  a  complete  failure  to  unite  on  the 
part  of  the  Miillerian  ducts.  The  consequent  deformities  of  the 
uterus  may  occasion  abnormalities  in  pregnancy  or  complications 
in  labor  and  after-delivery.     If  there  is  complete  disjunction  of  the 


Fig.  41. — Uterus  bicornis  unicollis :  a.  Vagina;    b,  single   neck;    c,  c,  horns;   d,d, 
tubes  ;  e,  e,  ovaries  ;  f,  f,  round  ligaments. 


Fig.  42. — Uterus  cordiformis  :  a,  Indented  fundus ;  b,  b,  tubes ;  c,  c,  round  liga- 
ments ;  d,  central  longitudinal  ridge  on  posterior  wall  of  uterine  cavity ;  e,  e,  lateral 
ridges  of  same  ;  f,  internal  os  ;  g,  g,  cervix. 


two  ducts,  the  deformity  is  known  as  uterus  didelphys  (Fig.  39). 
If  there  is  an  outward  junction  but  a  complete  disassociation  of  the 
two  tubes  except  for  their  superficial  union  externally,  the  condi- 
tion is  called  uterus  bicornis  duplex  (Fig.  40).    If  there  is  a  junction 


THE   FEMALE   SEXUAL    ORGANS. 


SI 


Fig.  43. — Uterus  incudiformis. 


Fig.  44. — Schematic  drawing  of  double  vagina  and  single  uterus  :  A,  Left  vagina  ;  B, 
right  vagina ;   C,  cervical  septum. 


Fig.  45. — Uterus  unicornis  :  LH,  Left  horn  ;  LT,  left  tube  ;  Lo,  left  ovary  ;  L  Lr, 
left  round  ligament;  RH,  right  horn  ;  RT,  right  tube;  Ro,  right  ovary;  R  Lr,  right 
round  ligament. 


52 


PREGNANCY. 


Fig.  46. — Ill-developed  uterus  unicornis  :  a.  Cervix  ;  b,  fundus  ;  c,  d,  longitudinal 
axis  of  uterine  body ;  e,  cornu  ;  f,  tube ;  g,  ovary ;  k,  ovarian  ligament ;  i,  round 
ligament ;   k,  parovarium. 


Fig.  47. — 111  development  of  right  side  of  uterus  ;   congenital  lateral  flexion. 


Plications. 


Fig.  48. — Longitudinal  section  of  Fallopian  tube,  exposing  the  complicated  longitu- 
dinal plications  of  the  mucosa  which  expand  into  the  limbria;  (Sappey). 


THE  FEMALE  SEXUAL    ORGANS.  53 

at  the  cervix  but  separation  of  the  ducts  above,  there  is  a  uterus 
bicornis  unicolHs  (Fig.  41).  There  may  be  complete  junction  of 
the  two  Miillerian  ducts,  but  the  fusion  of  the  two  canals  is  incom- 
plete ;  a  uterus  subseptus  or  semipartitus  is  the  result.  Finally, 
the  form  of  the  uterus  may  indicate  its  double  origin:  there  may 
be  a  uterus  cordiformis  (Fig.  42)  or  a  uterus  incudiformis  (Fig. 
43).  Occasionally  one  duct  of  Miiller  develops  normally  while 
the  other  is  present  as  a  mere  rudiment.  There  is,  in  consequence, 
a  uterus  unicornis  (Fig.  45). 

The  vagina  is  double  in  uterus  didelphys  and  often  in  uterus 
bicornis  duplex.  The  duplicity  of  the  birth-canal  may  be  con- 
fined to  the  vagina  (double  vagina)  or  it  may  affect  the  cervix 
without  involving  the  rest  of  the  uterus, — uterus  biforis  (Fig.  44). 

The  oviducts,  or  Fallopian  tubes,  are  tubular  structures 
about  10  or  £2^  cm.  (3.93  or  4.5  in.)  long,  running  from  the  cornua 
of  the  uterus  at  the  upper  edge  and  between  the  layers  of 
the  broad  ligament  outward,  upward,  and  at  their  outer  extremi- 
ties downward  and  backward  to  the  free  surface  of  the  ovar>'. 
The  canal  of  the  tube  begins  in  the  uterine  wall  as  a  fine 
opening  (ostium  internum) ;  it  expands  to  about  2  mm.  (0.079  ir^-) 
in  diameter,  becomes  wider  as  it  runs  outward,  again  contracts 
where  it  passes  the  ovary,  widens  again  to  a  distinct  opening 
4  mm.  (o.  157  in.)  in  diameter  (ostium  abdominale)  into  the  apex 
of  the  pavilion,  or  infundibulum,  a  funnel-shaped  expansion  at  its 
outer  extremity  surrounded  by  fringed  processes, — the  fimbriae.^ 
The  fimbriated  extremity  is  connected  with  the  ovary  by  the 
tubo-ovarian  ligament. 

The  tube  has  three  coats, — a  mucous,  muscular,  and  serous. 
The  mucous  membrane  of  the  tube  consists  of  a  single  layer  of 
columnar,  ciliated,  epithelial  cells,  the  cilia  lashing  toward  the 
uterine  cavity.  The  membrane  is  thrown  into  deep  longitudinal 
folds,  becoming  more  complex  as  the  fimbriated  extremity  is 
approached.  There  are  no  glands  in  the  mucous  membrane. 
The  muscular  coat  consists  of  circular  fibers  of  unstriped  muscle, 
with  an  outer,  ill-developed  layer  of  longitudinal  fibers.  The 
serous  covering  is  continuous  with  the  serous  covering  of  the 
broad  ligament. 

The  ovaries  are  almond-shaped  bodies  varying  in  size  in  differ- 
ent individuals  and  under  different  circumstances,  but  having  aver- 
age diameters  of  3.5  cm.  (1.38  in.)  in  length,  2  cm.  (0.79  in.)  in 
width,  and  1.5  cm.  (0.54  in.)  in  thickness.  They  are  attached  to 
the  posterior  layer  of  the  broad  ligament  by  the  hilum.  The  ovary 
is  a  gland  secreting  eggs.  It  has,  therefore,  a  gland-struc- 
ture, stroma,  parenchyma,   and  gland-spaces.      There  are,  how- 

*  Older  anatomists  divided  the  tube  into  the  isthmus,  comprising  the  inner  third, 
the  ampulla,  the  outer  or  expanded  portion,  and  the  fimbriae. 


54 


PREGNANCY. 


Y\g.  49. — Normal  Fallopian  tube,    uterine  end:   m.  Mucosa;    /,  lumen  of  canal 

t,  tube -wall. 


Fig.  50. — Normal    Fallopian    tube,    section    near  abdominal  end :    /,  Tubal    wall ; 
V,  villus-like  plications. 


THE  FEMALE   SEXUAL    ORGANS. 


55 


ever,  certain  distinctive  peculiarities  about  this  gland.  It  is 
not  covered  by  peritoneum,  but  by  a  modified  form  of  cells 
resembling  those  of  mucous  membrane, — the  germinal  epi- 
thelium. The  gland-spaces  have  no  ducts,  but  excrete  their 
contents  by  a  rupture  of  their  walls.  The  body  of  the  ovary  is 
divided  into  a  cortex  and  a  niedulla.     The  former  contains  the 


Fig.  51. — Section  through  part  of  ovary  of  adult  bitch  :  a,  Germinal  epithelium; 
b,  b,  ingrowths  (egg-tubes)  from  the  germinal  epithelium,  seen  in  cross-section  ;  <•,  r, 
young  Graafian  follicles  in  the  cortical  layer ;  d,  a  more  mature  follicle,  containing 
two  ova  (this  is  rare)  ;  e  and/",  ova  surrounded  by  cells  of  discus  proligerus ;  g^  k, 
outer  and  inner  capsules  of  the  follicle;  ?,  membrana  granulosa;  /,  blood-vessels; 
tn,  m,  parovarium  ;  g,  germinal  epithelium  commencing  to  grow  in  and  form  an  egg- 
tube;  z,  transition  from  peritoneal  to  germinal  epithelium  (from  Waldeyer). 


gland-spaces  called  Graafian  follicles  (after  their  discoverer,  Reg- 
nicr  dc  Graaf,  1673,  who  thought  they  were  ova),  set  in  a  stroma 
of  spindle-shaped  connective-tissue  cells.  The  latter  contain 
blood-vessels,  nerves,  a  few  muscle-fibers,  and  irregular  groups 
of  ^polyhedral  cells  (the  interstitial  cells),  representing  atrophic 
remains  of  the  Wolffian  bodies.     Besides  its  connection  with  the 


56 


PREGNANCY. 


posterior  layer  of  the  broad  ligament  by  the  hilum,  the  ovary  is 
attached  to  the  uterus  by  the  utero-ovarian  ligament,  to  the  tube 
by  the  tubo-ovarian  ligament,  and  to  the  pelvic  wall  by  the  sus- 


Fig.  52. — Section  of  human  ovary,  including  cortex :  a,  Germinal  epithelium  of 
free  surface ;  b,  tunica  albuginea ;  c,  peripheral  stroma  containing  immature  Graafian 
follicles,  d ;  e,  well-advanced  follicle  from  whose  wall  the  membrana  granulosa  has 
partially  separated;  f,  cavity  of  liquor  folliculi ;  g,  ovum  surrounded  by  cell-mass 
constituting  discus  proligerus  (Piersol). 

pensory  ligament  of  the  ovary  (ovario-pelvic,  infundibulo-pelvic 
ligament). 


A  B 

Fig-  53- — A,  Recently  ruptured  Graafian  follicle.    B,  Normal  Graafian  follicle  about  to 

rupture  showing  stigma  (Micro-photographs  prepared  by  McConnell  and  J.  C.  Hirst). 


MENSTR  UA  TION. 


57 


CHAPTER  II. 

Menstruation,  Ovulation,  Insemination,  and  Fertilization;  The 
Changes  in  the  Ovum  After  Fertilization. 

MENSTRUATION, 

Menstruation  is  the  periodic  discharge  of  a  sanguineous  fluid 
from  the  uterus,  and  perhaps  from  the  Fallopian  tubes,  during  the 
time  of  a  woman's  sexual  activity,  from  puberty  until  the  meno- 
pause. From  the  earliest  ages  of  medical  literature  many  theories 
have  been  advanced  to  account  for  menstruation.  The  oldest 
explanation  was  founded  upon  woman's  supposed  un cleanliness. 
Menstruation  was  thought  to  be  an  effort  on  the  part  of  nature  to 
rid  the  woman's  body  of  noxious  humors.*  Again,  it  was  explained 
that  woman  was  plethoric  and  that  nature  provided  a  periodic  vent 
for  the  superfluous  blood.  In  modern  times  Pfliiger  has  advanced 
the  theory  that  menstruation  occurs  in  consequence  of  a  conges- 
tion brought  about  as  follows  :  A  Graafian  follicle  by  its  growth 
finally  produces  so  great  a  reflex  irritation  as  to  determine  a  local 
congestion,  which  manifests  itself  in  a  bloody  discharge  from  the 
uterine  mucous  membrane.  Sigismund,  Lowenhardt,  and  Rei- 
chert  propounded  the  doctrine  that  menstruation  occurs  because 
the  ovum  discharged  prior  to  the  menstrual  period  is  not  impreg- 
nated ;  consequently,  failing  this  stimulus  to  further  growth  and 
development,  a  retrograde  change  with  bleeding  occurs  in  the 
uterine  mucous  membrane.  As  a  matter  of  fact,  the  cause  of 
menstruation  is  one  of  the  many  life -phenomena  at  present 
beyond  human  comprehension.  All  that  can  be  said  is  that  a 
nervous  influence  proceeds  periodically  from  the  sympathetic 
ganglia  in  the  lower  abdomen  and  pelvis,  stimulating  and 
congesting  the  sexual  organs.  We  can  no  more  account  for 
this  nervous  action  than  we  can  explain  the  nei'vous  force 
which  continues  respiration  from  the  moment  of  birth  until 
death.  Certain  facts  from  comparative  physiology,  however, 
throw  a  glimmer  of  light  upon  the  subject.      For  instance,  it  is 

^  Many  popular  superstitions  are  founded  upon  this  idea ;  for  example,  that  a 
drop  of  menstrual  blood  withers  a  flower,  and  that  a  menstruating  woman  in  a  dairy 
turns  the  milk  sour.  The  modern  physician  is  still  influenced  by  this  old  super- 
stition, if  the  author  may  judge  from  grave  discussions  he  has  heard  as  to  the  pro- 
priety of  allowing  a  menstruating  nurse  to  be  present  during  the  performance  of  an 
abdominal  section. 


$8  PREGNANCY. 

asserted  that  if  sheep  fall  into  heat  and  are  not  gratified,  the  rut 
returns  in  a  month.  Menstruation  in  the  female  is  obviously 
what  rut  is  in  the  lower  animals,  and  the  bloody  discharges  from 
human  females  are  probably  the  result  of  their  erect  posture  and 
the  pelvic  congestion  which  is  a  consequence  of  it. 

The  mechanism  of  menstruation  is  better  understood  than  its 
causes.  It  is  mainly  a  diapedesis  of  blood  through  delicate  new- 
formed  capillaries  in  a  thickened  and  congested  endometrium, 
the  provision  for  carrying  blood  to  the  membrane  being  better 
than  that  for  bearing  it  away  by  the  efferent  vessels.  Some  of 
the  newly  formed  delicate -walled  capillaries  no  doubt  rupture. 
Leopold  has  given  the  following  description  of  the  uterine  mu- 
cous membrane  during  menstruation  : 

The  mucous  membrane  is  8  mm.  (0.315  in.)  thick,  swollen, 
dark  brownish  red,  soft  almost  to  liquefaction,  but  perfectly  intact 
and  separated  by  a  sharply  defined  boundary-line  from  the  paler 
muscular  tissue  of  the  uterus.  The  uterine  glands,  0.5  to  0.75 
mm.  (0.0197  to  0.0296  in.)  wide,  are  considerably  lengthened 
and  can  be  seen  by  the  naked  e}'e.  In  the  superficial  portion  of 
the  mucous  membrane,  which  is  very  well  preserved  and  only  in 
certain  spots  lacks  its  epithelium  and  subjacent  cells,  may  be 
seen  an  immense  and  enormously  hypertrophied  capillary  net- 
work, the  vessels  of  which  have  irregular  outlines  and  lie  in  the 
uppermost  layer  of  the  mucous  membrane. 

Gebhard  ^  gives  the  following  results  of  his  studies  :  About 
ten  days  before  the  men.struation  there  is  a  serous  infiltration  of 
the  mucous  membrane,  separating  the  meshes  of  the  stroma. 
Just  before  the  flow  there  is  a  marked  dilatation  of  the  blood- 
vessels. The  glands  increase  in  size,  become  tortuous  in  their 
course,  and  are  dilated  by  secretion.  The  swollen  capillaries  in 
part  rupture,  in  part  permit  a  transudation  of  blood.  There  is 
an  extravasation  infiltrating  -the  stroma,  forcing  its  wa\'  up\vard 
under  the  epithelium,  which  it  raises  from  the  subjacent  tissues 
in  little  hillock-like  projections.  The  blood  escapes  into  the 
uterine  cavity  in  two  ways  :  First,  it  is  pressed  out  between  the 
epithelial  cells  of  the  intact  mucosa  ;  second,  the  greater  quantity 
by  far  makes  its  exit  through  openings,formed  by  the  separation 
of  the  cells  on  the  summits  of  the  hillocks  just  described.  If  the 
bleeding  is  profuse,  epithelium  may  be  carried  away  by  the 
blood-stream.  Exfoliation  of  the  epithelium,  however,  is  not  the 
rule.  After  the  exudation  and  transudation  of  blood  ceases,  the 
swollen  membrane  shrinks  again,  the  epithelium  sinks  to  its  nor- 
mal level  and  becomes  attached  to  subjacent  tissues.  The  ex- 
travasated  blood  in  the  stroma  is  absorbed. 

^  Veit's  "  Handbuch  der  Gynakologie,"  vol.  III. 


MENS  TR  UA  TION.  5  9 

From  these  observations  of  Leopold's  and  Gebhard's,  and 
from  other  studies  of  mucous  membrane  removed  by  the  curet 
during  menstruation  and  observed  in  recently  extirpated  uteri,  it 
appears  that  the  theory  of  hemorrhage  in  consequence  of  degen- 
eration of  the  mucous  membrane  is  untenable. 

The  uterus  is  increased  in  size  and  softened  in  consistency, 
these  changes  being  most  marked  just  before  the  flow  appears. 
The  uterine  cavity  is  enlarged,  the  cervix  is  slightly  dilated,  and 
the  cervical  glands  secrete  an  increased  amount  of  mucus.  The 
tubes  and  ovaries  are  swollen,  heavy,  and  congested. 

There  are  certain  clinical  phenomena  of  menstruation  which 
must  often  be  taken  into  account  by  the  ph}'sician. 

Time  of  First  Occurrence  and  of  Cessation. — The  onset 
of  menstruation  is  influenced  by  race,  climate,  mode  of  life, 
heredity,  and  genital  sense.  In  temperate  climates  and  in  the 
home  of  the  Teutonic  and  Anglo-Saxon  races,  menstruation 
occurs  oftener  in  the  fifteenth  than  in  any  other  year.  In  these 
same  races  transplanted  to  the  eastern  middle  sea-board  of  the 
United  States,  menstruation  appears  a  year  or  two  earlier. 

In  Hungary  the  three  races,  Slavonic,  Magyar,  and  Jew- 
ish, living  side  by  side  in  the  same  climate,  begin  to  menstru- 
ate, respectively,  at  sixteen,  fifteen,  and  thirteen  years  of  age. 
Hindu  girls  of  Calcutta  and  negresses  of  Jamaica,  living  in 
similar  climatic  conditions,  begin  to  menstruate  at  the  eleventh 
and  at  the  fifteenth  year.  Climate,  however,  does  influence  the 
onset  of  menstruation.  It  appears  at  eighteen  years  in  the  girls 
of  Lapland  and  at  ten  years  in  Egypt  and  Sierra  Leone. 

The  social  conditions  of  a  girl  determine,  to  a  certain  extent, 
the  age  at  which  menstruation  begins.  If  she  lives  in  a  city, 
subjected,  perhaps,  to  indiscriminate  association  with  the  other 
sex  and  to  sexual  temptations,  the  function  appears  earlier  than 
it  does  in  the  country,  or  in  a  girl  carefully  brought  up  in  com- 
parative seclusion.  The  same  rule  applies  to  lower  animals.  If 
a  bull  is  admitted  to  the  pasture  of  a  herd  of  heifers,  heat 
appears  earlier  in  the  latter  than  it  would  if  the}*  were  segre- 
gated. 

It  is  a  matter  of  common  observation  that  peculiarities  of 
menstruation  run  in  certain  faniilies.  Thus,  through  several  gen- 
erations of  females  menstruation  appears  late  and  ends  early,  or 
vice  versa.  By  genital  sense  is  meant  the  strength  of  sexual 
feeling.  In  women  of  strong  sexual  passion  the  function  of 
menstruation  is  commonly  instituted  earlier  and  lasts  to  a  greater 
age  than  common.  Precocious  menstruation  is  not  uncommonly 
associated  with  nj'mphomania. 

Menstrual  Molimina. — By  this  term  is  meant  the  local  and 


6o  PREGNANCY. 

reflex  subjective  symptoms  of  menstruation.  There  is  a  feeling 
of  weight  and  heaviness  in  the  pelvic  organs,  due  to  their  con- 
gestion and  increase  of  size.  There  is  a  general  nervous  ex- 
citation, so  that  women  disposed  to  hysteria  and  epilepsy  exhibit 
outbreaks  at  this  and  perhaps  at  no  other  time.  The  breasts 
swell  and  may  secrete  milk.  The  thyroid  gland  is  enlarged  and 
the  tonsils  are  swollen,  so  that  singers  may  lose  their  voice. 
There  is  increased  vascular  tension,  increased  activity  of  the 
heart,  shown  by  sphygmographic  tracings,  and  the  pulse  is 
accelerated.  The  temperature  is  elevated  by  0.5°  C.  The  skin 
is  more  vascular  and  shows  unusual  pigmentation,  especially  in 
the  dark  rings  under  the  eyes.  v.  Ott  has  demonstrated  a  regu- 
larly recurring  wave  in  all  the  physiological  processes  of  women, 
shown  by  heat  production,  muscle  strength,  lung  capacity,  force 
of  inspiration  and  expiration,  and  tendon  reflexes.  The  greatest 
activity  is  manifested  just  before  the  appearance  of  the  flow,  when 
there  is  a  sudden  subsidence. 

The  Character  of  the  Flow. — The  discharge  consists,  in 
great  part,  of  blood.  It  is  alkaline  in  reaction.  It  contains, 
besides  blood,  mucous  secretion  from  the  glands  along  the 
genital  canal  and  epithelial  cells.  It  is  dark  in  color,  and  should 
not  clot.  It  has  a  peculiar  odor  from  the  secretions  of  the 
sebaceous  elands  at  the  vaginal  outlet,  excited,  as  are  all  the 
structures  of  the  genital  canal,  to  unusual  activity. 

The  Duration  of  the  Flow. — Menstruation  rarely  lasts  less 
than  three  days  ;  a  continuance  of  four,  five,  or  seven  days,  if 
the  natural  and  invariable  habit  of  the  individual,  may  indicate 
nothing  pathological.  In  the  first  two  or  three  days  the  greatest 
amount  of  blood  is  lost.  After  that  the  discharge  grows  less 
until  it  ceases.  A  leukorrhea  or  mucous  discharge  for  a  day  or 
two  after  the  cessation  of  the  bloody  flow  is  common. 

The  Quantity  of  the  Flow. — The  actual  quantity  of  dis- 
charge during  menstruation  has  been  estimated  at  four  to  six 
ounces.  It  is  not  practicable  for  the  physician,  however,  accur- 
ately to  measure  the  amount  of  flow.  He  must  estimate  it  by 
the  number  of  napkins  worn  in  twenty-four  hours.  If  a  woman 
is  obliged  to  change  her  napkins  during  the  height  of  the  flow 
more  than  three  times  a  day,  or  to  wear  them  double,  the  quan- 
tity of  the  flow  is  excessive. 

The  Cessation  of  the  Flow The  menstrual  flow  ceases  usu- 
ally in  the  forty-fifth  year,  becoming  infrequent  and  more  scanty 
over  a  period  of  six,  nine,  or  twelve  months,  until  it  stops  alto- 
gether. There  are  many  exceptions,  however,  to  this  rule.  A 
woman  who  begins  to  menstruate  much  later  than  the  fifteenth 
year   will  often  have  the  menopause  before  forty.      Or,   if  she 


OVULATION.  6 1 

begins  to  menstruate  early,  she  will  often  continue  beyond  the 
forty-fifth  year. 

As  a  rule,  therefore,  it  may  be  stated  that  a  woman  menstru- 
ates from  about  the  fourteenth  to  the  forty -fifth  year  of  her  age. 
Precocious  menstruation,  however,  has  been  recorded  in  the 
infant  of  one  or  two  years  old,  and  the  discharge  has  continued 
to  the  sixty-fifth  and  even  to  the  eightieth  year. 

OVULATION. 

By  ovulation  is  meant  the  discharge  of  a  mature  ovum 
from  its  Graafian  follicle.  The  study  of  the  process  involves 
a  consideration  of  the  development  of  the  Graafian  follicle 
and  its  rupture ;  the  maturation  of  the  ovum ;  the  transmi- 
gration of  the  ovum  from  the  surface  of  the  ovary  to  the 
uterine  cavity. 

The  Development  of  the  Graafian  Follicle  and  its  Rup= 
ture. — The  germinal  epithelium  on  the  surface  of  the  ovary 
sends  down  into  the  ovarian  stroma  columnar  prolongations 
called  egg-cords.  These  cords  become  constricted  at  intervals, 
so  that  they  are  converted  into  a  number  of  spherical  gland- 
spaces  unconnected  with  one  another  and  without  efferent  ducts. 
The  gland-space  is  surrounded  by  a  containing  membrane  (the 
theca  folliculi)  divided  into  two  layers, — the  tunica  fibrosa  and 
the  tunica  propria.  The  interior  of  the  gland-space  is  lined  with 
a  layer  of  epithelial  cells, — the  membrana  granulosa.  One  of 
these  cells,  more  highly  specialized  than  the  rest,  the  ovum 
(discovered  by  K.  E.  von  Baer,  1827),  is  surrounded  by  an 
aggregation  of  the  cells  of  the  membrana  granulosa, — the 
proligerous  disc.  The  cavity  of  the  gland-spaces  is  dis- 
tended with  fluid  (the  liquor  folliculi)  containing  paralbumin. 
As  the  Graafian  follicle  develops,  it  retires  deeper  into  the  in- 
terior of  the  ovary,  following  the  direction  of  least  resistance. 
Finally,  however,  the  most  mature  follicle,  under  the  influence 
of  premenstrual  congestion,  rapidly  secretes  liquor  folliculi, 
swells  to  the  size  of  a  pea  or  a  cherry,  so  that  it  stands  out 
plainly  from  the  surface  of  the  ovary.  On  the  most  promi- 
nent portion  of  its  free  periphery  the  tunica  propria  fails  at  one 
spot  (the  stigma),  so  that  the  integrity  of  the  follicle  is  preserved 
only  by  the  tunica  fibrosa,  which  soon  gives  way  under  the 
pressure  imposed  upon  it  from  within,  and  the  follicle  ruptures. 
The  ovum  and  surrounding  discus  proligerus,  usually  attached  to 
the  follicle-wall  just  under  the  stigma,  are  washed  out  into  the  free 
peritoneal  cavity  by  the  escaping  liquor  folliculi. 

The   Maturation    of   the   Ovum. — The    primordial   ovum  in 


62 


PREGNANCY. 


the  immature  Graafian  follicle   is   an  epithelial  cell  without   a 

cell-wall,  but  with  cell-con- 
tents called  the  yolk,  a  nu- 
cleus called  the  germinal  vesi- 
cle, and  a  nucleolus  called  the 
germinal  spot.  As  the  ovum 
matures,  it  acquires  a  cell-wall 
with  three  coats  or  layers, — 
the  zona  pellucida,  the  vitelline 
membrane,  and  the  internal 
cell-membrane.  The  human 
ovum  is  holoblastic, — that  is, 
it  completely  segments, — and 
contains  much  more  proto- 
plasm, or  germ-yolk,  than 
deutoplasm,  or  food-yolk.  In 
its  maturation,  or  preparation 
for  impregnation,  the  ovum 
shows  the  curious  movement 
of  its  nucleus  observable  in 
all  segmenting  cells  (karyoki- 
nesis),  w^hich  approaches  the 
cell-periphery,  arranges  itself 
in  two  star-shaped  figures  by 
the  activity  of  the  centrosome 
(the    amphiaster    stage),    and 


Sq  ti      Up        K 

54. — Section  through  part  of  a 
mammalian  ovary  :  KE,  Germinal  epitheli- 
um ;  PS,  an  egg-cord  ;  U,  U,  primitive  ova ; 
G,  investing  cells ;  J^,  germinal  vesicle  ; 
S,  follicular  cavity  arising  in  one  of  the 
older  follicles ;  Lf,  follicular  cavity,  more 
enlarged  ;  Ei,  nearly  mature  ovum,  which 
has  developed  around  it  the  zona  pellu- 
cida, Mp ;  Mg,  membrana  granulosa ;  D, 
Discus  proligerus ;  So,  ovarian  stroma ; 
Tf,  capsule  of  follicle  ;  g,g,  blood-vessels; 
u,  immature  Graafian  follicle  (after  Wie- 
dersheim). 


extrudes  portions  of  its  sub- 
stance as  little  globules  (polar  globules)  upon  the  ovular  surface, 
the  chromatin  in  the  nucleus  dividing  into  sixteen  chromosomes 
for  the  ovum  and  the  same  number  for  the  polar  globule  at  each 
extrusion  of  the  latter.  These  globules  then  disappear  and  are 
lost.  It  is  supposed  that  they  contain,  perhaps,  substances  which 
might  unite  with  the  female  portions  of  the  ovum  to  produce  an 
imperfect  being,  as  is  done  in  certain  hermaphroditic  animals. 
Nature,  it  is  presumed,  takes  this  measure  to  prevent  partheno- 
genesis, or  the  closest  kind  of  inbreeding.  A  similar  action 
may  be  observed  in  the  spermatozoon  during  its  development. 
After  the  extrusion  of  the  polar  globules  the  nucleus  retreats  into 
the  interior  of  the  ovum  and  becomes  the  female  pronucleus. 
The  chromosomes  are  reduced  in  number  one-half,  so  that  by  a 
similar  reduction  in  the  male  pronucleus  the  number  characteristic 
of  the  human  species,  sixteen,  is  maintained  when  the  two  unite. 
The  ovum  is  now  ready  for  fertilization. 

The  Discharge  of  the  Ovum  from  the  Ovary  and  its  Migra= 
lion  to  the  Uterine  Cavity. — Ova  are  discharged  from  the  ovary 
from  puberty  until  the  menopause, — that  is  to  say,  on  the  average, 


O  VULA  TION. 


63 


from  the  fourteenth  to  the  forty-fifth  year.  Ovulation,  however, 
may  begin  before  menstruation,  may  cease  before  the  menopause, 
or  possibly  may  continue  after  it.  A  young  girl  has  been  im- 
pregnated as  early  as  the  ninth  year.^     In  the  child-marriages  of 


f^^ — pb' 


Fig-  55- — Formation  of  polar  bodies  in  ova  of  Asterias  glacialis :  ps.  Polar 
spinale  ;  pb' ,  first  polar  body;  pb'',  second  polar  body;  n,  nucleus  returning  to 
condition  of  rest  (Hertwig). 

India  impregnation  has  occurred  before  menstruation  had  begun; 
but  usually  premature  maternity  is  preceded  by  precocious  men- 
struation.    Ovulation  has  continued,  as  proved  by  impregnation. 


Fig-  56. — A,  Mature  ovum  of  echinus :   «,  female  pronucleus;    B,  immature  ovarian 
ovum  of  echinus  (Hertwig). 

until  the  fifty-second,  fifty-fourth,  fifty-eighth,  and  even  to  the  six- 
tieth and  sixty-second  year  !  A  case  is  recorded  of  delivery  at  the 
age  of  fifty-nine  years  and  five  months,  and  one  at  the  age  of  sixty- 

'  Strassmann  lias  collected  six  cases  of  precocious  pregnancy  from  eight  years  and 
ten  months  to  ten  years  of  age.     "  Handbuch  d.  Gehurtsh.,"  v.  Wmckel,  vol.  i,  p.  91. 


64  PREGNANCY. 

one.  1  A  physician  investigating  the  nature  of  an  abdominal 
tumor  should  remember,  therefore,  that  pregnancy  is  possible 
from  the  ninth  to  the  sixty-second  year.  After  the  ovum  is  dis- 
charged from  the  ovary  it  is  caught  in  a  current  of  fluid  moist- 
ening the  surface  of  the  ovary,  and  is  carried  to  the  interior  of 
the  corresponding  tube.  The  existence  of  this  current  of  fluid 
is  explained  by  the  movement  of  the  ciliated  epithelium  in  the 
tubes.  In  some  animals  there  is  a  development  of  ciliated  epi- 
thelium on  the  peritoneum  at  the  time  of  ovulation.  Arrived  in 
the  tube,  the  ovum  is  transported  to  the  uterine  cavity  by  the 
movement  of  the  cilia  on  the  epithelium  and  by  the  vermiform 
movements  of  the  tubal  walls.  In  certain  cases  of  extra-uterine 
pregnancy  an  anomalous  transmigration  of  the  ovum  has  been 
demonstrated.  Thus  it  is  possible  for  the  ovum,  after  its  dis- 
charge from  the  ovary,  to  be  taken  up  by  the  fimbriated  extremity 
of  the  opposite  tube, — an  external  transmigration  of  the  ovum.  It 
is  also  possible  for  the  ovum  to  traverse  one  tube  and  the  uterine 
cavity  and  to  enter  the  uterine  ostium  of  the  opposite  tube, — an 
internal  transmigration  of  the  ovum. 

It  has  been  calculated  that  the  human  ovar}'  at  birth  contains 
70,000  ova.  As  it  is  unlikely  that  any  woman  discharges  many 
more  than  360  ova,  even  if  she  ovulates  uninterruptedly  for  thirty 
years,  an  enormous  number  of  ova  must  atrophy,  disintegrate, 
and  disappear  within  the  ovary. 

THE  CORPUS  LUTEUM. 

The  changes  which  occur  in  the  Graafian  follicle  after  its  rup- 
ture and  the  discharge  of  the  ovum,  discus  proligerus,  and  liquor 
folliculi  lead  to  a  formation  within  the  Graafian  follicle  called  the 
corpus  luteum. 

There  is  an  effusion  of  blood  into  the  cavity  of  the  follicle  and 
an  enormous  development  of  the  connective-tissue  elements  in 
the  follicle-wall.  ^  The  internal  layer  of  the  theca  folliculi  is  enor- 
mously thickened  and  thrown  into  numerous  folds  which  eventu- 
ally fill  up  the  whole  space  in  the  interior  of  the  folHcle.  The  mem- 
brane is  composed  mainly  of  large  hexagonal  cells,  like  those  of  the 
liver,  the  lutein  cells,  containing  a  yellow  substance — lutein — solu- 
ble in  alcohol,  and  fat  globules.  The  cells  are  separated  by  ray- 
hke  septa,  extensions  of  fibro- connective  tissue  from  the  theca. 
Leopold  thus  describes  the  development  of  the  typical  corpus 
luteum  :  It  appears  on  the  first  day  as  a  folhcle  just  broken  open, 
the  interior  filled  with  blood.      From  the  eighth  day  on  there 

1  Strassmann  quotes  cases  of  impregnation  at  the  sixty-second,  sixty-third,  and 
seventieth  year.      "  Handbuch  der  Geburtsh.,"  v.  Winckel,  vol.  i,  p.  95. 

2  "The  Origin,  Growth,  and  Fate  of  the  Corpus  Luteum  as  Observed  in  the  Ovary 
of  the  Pig  and  Man."     J.  G.  Clark,  "Johns  Hopkins  Hospital  Reports,"  vol.  vii. 


OVULATION  AND   MENSTRUATION.  6$ 

appears  a  fine  capsule  around  the  blood-extravasation,  while  the 
inner  portion  becomes  lighter  and  clearer.  From  the  twelfth  day 
the  capsule  grows  thicker  and  is  thrown  into  folds  ;  from  the 
sixteenth  day  it  becomes  a  pale  red,  merging  into  a  yellow. 
About  the  twentieth  day  the  central  matter  of  the  broken  follicle 
has  become  much  shrunken,  while  the  capsule,  more  decidedly 
a  pale  yellow,  projects  toward  the  center  of  the  follicle  in  rays 
and  narrow  folds.  The  corpus  luteum  of  menstruation,  or  the  so- 
called  false  corpus  luteum,  reaches  its  highest  development  in 
ten  to  thirty  days.  Nine  days  later  it  is  merely  a  lamina  of 
fibrous  tissue  beneath  a  little  pit  or  depression  of  the  ovarian 
surface.  The  true  corpus  luteum  of  pregnancy,  so  called,  is 
simply  an  exaggeration  of  the  corpus  luteum  of  menstruation,  the 
longer  growth  and  greater  size  being  due  to  the  stimulation  and 
congestion  of  gestation.  It  grows  for  thirty  or  forty  days  after 
conception,  occupying  a  third,  perhaps,  of  the  ovarian  area.  It 
then  remains  stationary  until  after  the  fourth  month,  when  it  begins 
to  atrophy  ;  at  term  it  is  only  two-thirds  its  largest  size  ;  one 
month  later  it  is  reduced  to  a  small  mass  of  fibrous  tissue.  The 
true  corpus  luteum  is  of  value  as  an  indication  of  the  ovary  from 
which  the  impregnated  ovule  came.  It  should  be  remembered, 
however,  that  the  ovaries  of  virgins  have  exhibited  corpora  lutea 
like  those  of  pregnancy  in  consequence  of  intense  and  prolonged 
congestion. 

It  is  claimed  that  there  is  a  secretion  from  the  corpus  luteum 
which  influences  the  nutrition  of  the  uterus,  the  occurrence  of 
menstruation,  and  the  development  of  the  ovum  and  of  the  uterus 
in  early  pregnancy.  Experiments  and  observations  of  Fraenkel 
and  others,  it  is  asserted,  demonstrate  that  an  overproduction  of 
lutein  cells  in  the  ovary  causes  a  hyperplasia  of  the  syncytial 
cells  of  the  trophoblast  and  that  a  destruction  of  the  corpus  luteum 
in  early  pregnancy  blights  the  ovum.^  This  statement  has  been 
denied,  but  it  is  now  generally  admitted  that  the  corpus  luteum  is 
the  most  important  source  of  the  internal  secretions  of  the  ovum, 
and  that  these  secretions  not  only  influence  the  sexual  organs  of 
women,  but  have  a  peculiar  influence  upon  the  other  organs  with 
internal  secretions,  such  as  the  pancreas.- 

THE   CONNECTION    BETWEEN    OVULATION  AND 
MENSTRUATION. 

Neither  one  of  these  functions  is  dependent  upon  the  other, 
but  they  both  depend  upon  a  common  cause, — the  periodic 
nervous  excitation  and  congestion  due  to  an  impulse  from  the 

1  Fraenkel  :  "  Die  Funktion  des  Corpus  luteum,"  Arch.  f.  Gyn.,  Bd.  Ixviii. 
''Rebaudi,  Zentralbl.  f.  Gyn.,  No.  41,  igoS, 
5 


66  PREGNANCY. 

sympathetic  nervous  system.  Dependent  as  they  are  upon  the 
same  cause,  their  occurrence  is  usually  synchronous, — that  is, 
the  ovule  is  discharged  at  the  height  of  menstrual  congestion. 
But  this  is  by  no  means  the  invariable  rule.  Leopold,  ^  in  an 
examination  of  twenty-nine  pairs  of  ovaries  removed  on  suc- 
cessive days  up  to  the  thirty -fifth  after  a  menstrual  period,  found 
a  Graafian  follicle  bursting  on  the  eighth,  twelfth,  fifteenth, 
sixteenth,  eighteenth,  twentieth,  and  thirty-fifth  day  after  the 
menstrual  period.  In  other  words,  ovulation  may  occur  without 
menstruation  at  any  time  in  the  intermenstrual  interval.  In  five 
cases  there  was  no  ovulation  at  the  menstrual  period,  or  men<- 
struation  occurred  without  ovulation.  Many  examples  might  be 
given,  from  clinical  observation,  of  the  mutual  independence  of 
these  two  functions.  The  common  occurrence  of  impregnation 
during  lactation  is  a  good  instance  of  ovulation  without  men- 
struation. ^  Menstruation  after  oophorectomy  and  during  the 
first  three  months  of  pregnancy  occurs  without  ovulation.  I 
attended,  in  her  first  childbirth,  a  young  woman  twenty-two  years 
old,  who  had  never  menstruated.  She  had  obviously,  however, 
ovulated.  In  the  child  marriages  of  India  impregnation  has  been 
known  to  precede  menstruation.  Renoudin  saw  pregnancy  and 
labor  in  a  woman  sixty-one  years  old,  who  had  ceased  to 
menstruate  twelve  years  before.  Repeated  ovulation  without 
menstruation  is  seen  also  in  those  curious  cases  of  postmarital 
amenorrhea,  lasting  for  years.  The  wife  of  a  physician  among 
my  acquaintances  menstruated  once  after  marriage  ;  in  the  fol- 
lowing fifteen  years  she  bore  ten  children  without  ever  men- 
struating. Three  years  after  the  birth  of  the  last  child,  or 
eighteen  years  since  its  cessation,  menstruation  returned  copi- 
ously and  regularly,  but  more  frequently  than  normal,  for  twelve 
years.  The  menopause  then  began,  at  the  age  of  fo rt}' -eight.  ^ 
A  recent  ovulation  has  been .  observed  in  an  extra-uterine  preg- 
nancy of  three  months'  duration  (Slavjansky).  Coitus  four  days 
postpartum  has  resulted  in  impregnation  (Kronig). 

It  is  sometimes  necessary  to  resort  to  oophorectomy  in  cases 
of  ill-developed,  infantile  wombs,  or  entire  absence  of  the  uterus 
associated  with  well-developed  ovaries,  in  which  there  is  a  violent 
exaggeration  of  the  menstrual  molimina  every  month  without  a 
discharge  of  blood  and  the  consequent  relief  of  menstrual  conges- 

1  "Archiv  f.  Gyn.,"  Bd.  xxix,  S.  347. 

2  Remfry  ("  Revue  internationale  de  Medicine  et  de  la  Chimrgie,"  1S96,  No.  5) 
has  found  by  an  investigation  among  900  nursing  women  that  in  57  per  cent,  only 
did  there  occur  an  absolute  amenorrhea.  Menstruation  was  regular  in  20  per  cent, 
and  irregular  in  43  per  cent.  It  was  also  common  for  conception  to  occur  during 
lactation,  60  per  cent,  of  the  menstruating  women  conceiving.  Among  the  non- 
menstruating  women  but  6  per  cent,  conceived  during  lactation. 

3  Similar  cases  are  reported  in  "Amer.  Jour,  of  Obstetrics,"  1892,  p.  352,  and 
"N.  Y.  Med.  Record,"  1893,  p.  717. 


INSEMINA  TION. 


67 


tion.  The  ovaries  are  found,  after  their  removal,  to  be  filled  with 
well-developed  Graafian  folHcles  and  numerous  depressions  repre- 
senting corpora  lutea.  It  may  also  be  necessary  to  remove  ovaries 
left  in  the  abdomen  in  a  hysterectomy  possibly  years  before.  The 
menstrual  molimina  are  so  severe  as  to  cause  occasionally  hysterical 
convulsions. 


INSEMINATION. 

By  the  term  insemination  is  meant  the  ejaculation  of  seminal 
fluid  from  the  male  organ  and  its  deposition  within  the  genital 
canal  of  the  female.  The  study  of  insemination  involves  a  con- 
sideration of  the  seminal  fluid,  the  development  and  life-history 
of  its  active  constituent  (the  spermatozoa),  the  mechanism  of  its 
ejaculation  from  the  penis,  and  of  its  reception  within  the  vagina 
and  womb. 

The  seminal  fluid  is    yellowish  white    in  color,   thick    and 
sticky  in  consistency,  varying  in  quantity  at  each  emission  from 
one-fourth  to  two  drams.    It  possesses  a  peculiar 
odor  and  is  neutral  or  alkaline  in  its  reaction.  ^  ^ 

The  constituent  parts,  on  chemical  examin- 
ation, are  found  to  be  water,  eighty-two  per 
cent.;  salts,  mainly  phosphates  ;  protein  matter, 
fats,  albumose,  nuclein,  lecithin,  guanin, 
hypoxanthin,  cholesterin,  and  spermatin.  On 
microscopical  examination  there  are  seen 
seminal  cells,  crystals  of  phosphates,  and 
spermatozoa,  discovered  by  Hammen  in  1677 
and  demonstrated  to  be  the  active  principle  in 
fertilization  by  the  filtration  experiments  of 
Spallanzani  and  others.  A  spermatozoon  is 
5-g-Q-  of  an  inch  in  length  and  possesses  a  power 
of  motion  by  which  it  can  travel  with  a  rapidity 
variously  estimated :  its  own  length  in  a  second, 
one  inch  in  seven  and  one-half  minutes  ('Henle), 
or  from  the  hymen  to  the  neck  of  the  womb 
in  three  hours  (Marion  Sims).  Sperm.atozoa 
have  been  found  in  the  uterine  cavity  thirty 
minutes  after  a  coitus  (Schuwarski) ;  in  the 
tube  sixteen  hours  post  mortem  in  a  prostitute 
who  was  killed  during  coitus.  Strassmann 
calculates  that  they  should  make  their  way  to 
the  infundibulum  of  the  tube  in  an  hour  and  a 
half.  Their  progressive  force  is  sufficient  to 
overcome  obstacles  that  appear  insuperable; 
they  may  be  seen,  under  the  microscope,  to  push  aside  epithelial 


Fig.  57.  —  Hu- 
man spermatozoa :  A, 
Speimatozoon  seen  en 
face;  h,  head;  m, 
middle-piece;  t,  tail; 
e,  end-piece;  B,  C, 
seen  from  the  side 
(after  Retzius). 


68 


PREGNANCY. 


cells  ten  times  their  size.  Their  vitality  under  favorable  cir- 
cumstances is  remarkable.  They  have  been  found  alive  in  the 
testicles  of  criminals  who  had  been  executed  three  days,  and  of 
bulls  which  had  been  killed  six  days  before.  In  the  cow  they  have 
been  found  six  days  after  insemination;  in  a  rabbit,  eight  days; 
in  the  female  bat  they  may  be  found  alive  for  months,  and  in  the 
queen-bee  for  three  years.  In  the  human  female  living  spermatic 
particles  have  been  found  in  the  vagina  seven  and  one-half  to 


Fig.  58. — a-h.  Isolated  sperm-cells  of  the  rat,  showing  the  development  of  the 
spermatozoon  and  the  gradual  transformation  of  the  nucleus  into  the  spermatozoon 
head.  In  g,  the  seminal  granule  is  being  cast  off  (after  H.  H.  Brown),  i—ni. 
Sperm-cells  of  an  elasmobranch ;  the  nucleus  of  each  cell  divides  into  a  large  number 
of  daughter-nuclei,  each  of  which  becomes  converted  into  the  rod-shaped  head  of  a 
spermatozoon  (after  Semper),  n,  Transverse  section  of  a  ripe  cell,  showing  the 
bundle  of  spermatozoa  and  the  passive  nucleus  (/,  n,  after  Semper),  o-s.  Sperma- 
togenesis in  the  earthworm ;  o,  young  sperm  cell ;  /,  the  same  divided  into  four ; 
q,  spermatophore  with  the  central  sperm-blastophore  ;  r,  a  later  stage ;  s,  nearly 
mature  spermatozoa  (after  Blomfield)  (from  Haddon). 

seventeen  days,  in  the  cervical  canal  eight  days  after  copulation.^ 
They  have  been  found  ahve  in  the  tubes  three  and  a  half  weeks 
after  the  last  coitus  (Diihrssen),  and  have  been  kept  alive  in  a 
culture-oven  for  eight  days.  On  the  contrary,  they  are  extremely 
susceptible  to  certain  unfavorable  influences.  They  are  destroyed 
by  heat,  cold,  acid  solutions,  lack  of  water,  and  the  mineral  poi- 

1  "Handbuch  d.  Geb.,"  v.  Winckel,  vol.  i,  p.  146. 


INSEMINA  TION. 


69 


sons.  A  solution  of  bichlorid  of  mercury,  i  :  10,000,  is  fatal  to 
them.  As  a  consequence  of  chronic  disease  in  the  man,  of  alco- 
holic or  sexual  excess,  or  of  catarrh  of  the  seminal  vesicles,  the 
spermatozoa  may  be  dead  when  emitted.  As  a  result  of  inflam- 
mation and  obliteration  of  the  seminal  ducts  or  of  anatomical  de- 
fects the  seminal  particles  may  be  absent  from  the  seminal  fluid. 
Lode  estimates  that  there  should  be  about  60,000  spermatozoa 
to  the  cubic  millimeter  of  semen.  Therefore  millions  of  these 
bodies  are  deposited  in  the  vagina  at  each  coitus. 


Fig-  59- — Seven  stages  of  the  conversion  of  a  spermatic  cell  into  a  spermatozoon 
(Meves).  Figs,  a  to/.-  Zs,  Cell  contents  ;  K,  nucleus  ;  PC,  proximal  central  body  ; 
jfC,  distal  central  body;  SF,  tail-piece.  Fig.  g:  Head-piece;  Ekn,  neck;  Vst, 
junction  piece;   list,  main  piece;   Est,  end-piece. 

The  indifferent  constituent  parts  of  the  seminal  fluid  are 
derived  from  Cowper's  glands,  the  prostate,  and  the  vcsiculae 
seminales.  The  spermatozoa  arc  developed  from  mother-cells, 
or  spermatoblasts,  specialized  from  the  e])ilhclium  of  the  testicle. 
In   the   course  of    their    development    a    portion    of    the    ceH    is 


'JO  PREGNANCY. 

extruded  (seminal  granule  or  accessory  corpuscle)  just  as  in 
the  maturation  of  the  ovum  the  polar  globules  are  cast  off. 
In  the  fully  developed  spermatozoon  the  head  represents  the 
nucleus  of  an  epithelial  cell,  and  the  tail  cell-contents  specialized 
in  the  form  of  a  cilium,  of  much  larger  size  and  greater  power, 
however,  than  the  cilia  of  ordinary  ciliated  epithelium. 

Spermatic  particles  first  appear  in  the  seminal  fluid  at  about 
the  fifteenth  or  sixteenth  year.  There  is  often,  in  boys  of  twelve 
or  thirteen,  a  seminal  discharge,  but  it  contains,  as  a  rule,  no 
spermatic  particles.  I  have  had  charge,  however,  of  a  girl  four- 
teen years  of  age  impregnated  by  her  brother,  aged  thirteen,  who 
had  stimulated  his  sexual  development  by  masturbation.  Sper- 
matozoa often  disappear  from  the  sexual  discharge  of  old  men, 
but  the  age  at  which  this  disappearance  occurs  varies  greatly! 
As  a  general  rule  it  might  be  put  down  as  sixty-five,  but  it  will 
be  remembered  that  the  French  engineer,  de  Lesseps,  was  a 
father  at  eighty-two,  and  that  old  Thomas  Parr  illegitimately 
impregnated  a  woman  after  he  had  passed  his  hundredth  birth- 
day. 

The  Mechanism  of  the  Ejaculation  of  Seminal  Fluid  and 
of  its  Reception  within  the  Genital  Canal  of  the  Female. 
— The  mechanism  of  ejaculation  is  only  understood  by  a  study 
of  the  anatomy  of  the  penis,  which  need  not  be  considered  here. 
It  is  sufficient  to  state  that  at  the  height  of  the  orgasm  in  the 
male  the'  seminal  fluid  is  emitted  by  the  action  of  the  circular 
and  longitudinal  muscle-fibers  of  the  vesiculae  seminales  and  of 
the  urethra.  The  mechanism  of  the  reception  of  the  fluid  within 
the  genital  canal  of  the  female  is  a  much  more  important  matter 
to  the  obstetrician,  for  on  a  knowledge  of  this  subject  depends 
the  comprehension  of  many  a  case  of  conception  and  of  sterility. 

It  has  been  found,  in  studying  the  sexual  congress  of  animals, 
especially  in  horses,  that  during  the  emission  of  semen  and  for  a 
short  time  afterward  the  uterus  exerts  an  intermittent  suction,  or 
aspiration  action,  upon  the  seminal  fluid,  drawing  it  into  the  uter- 
ine cavity.  In  the  observation  of  sexual  excitement  in  bitches  it 
has  been  noticed  that  the  uterus  is  drawn  down  into  the  small 
pelvis.  In  experimenting  with  the  electrical  stimulation  of  the 
sexual  organs  in  female  animals,  it  was  observed  that  the  uterus 
grew  shorter,  but  broader ;  that  it  descended  toward  the  vaginal 
outlet ;  that  the  cervix  projected  farther  than  normal  into  the 
vaginal  canal,  at  the  same  time  becoming  softer  and  shorter,  but 
broader,  by  which  action  the  os  uteri  was  opened.  The  stimulus 
being  removed,  the  uterus  returned  to  its  normal  condition  and 
the  OS  closed. 


INSEMINA  TION.  J I 

These  interesting  experiments  upon  animals  have  been  con- 
firmed by  observations  which  gynecologists  occasionally  have  the 
opportunity  of  making  upon  erotic  females  during  a  specular 
examination.  It  is  justifiable,  therefore,  to  state  that  in  the 
orgasm  a  woman's  uterus  becomes  broader  and  shorter;  that  it 
descends  into  the  small  pelvis  ;  that  the  cervix  projects  into  the 
vagina,  becomes  broader,  shorter,  and  softer,  and  that  the  os 
opens ;  these  actions  being  intermittent,  the  uterus  might  be 
likened  to  an  animal  gasping  for  breath.  It  would  appear  that 
the  intention  of  this  action  is  to  suck  the  seminal  fluid  directly 
into  the  uterine  cavity.  The  postmortem  examination  of  two 
women  murdered  at  the  conclusion  of  a  copulation  in  whom  the 
uterine  cavity  was  found  fijll  of  seminal  fluid  does  not,  therefore, 
seem  necessarily  apocryphal,  though  the  reports  date  from  an 
unscientific  a^e,  and  have  been  used  as  the  foundation  of  absurd 
theories.  1 

A  perfectly  normal  and  typical  mechanism  of  the  reception  of 
seminal  fluid  may  be  thus  briefly  described  :  The  orgasm  of  male 
and  female  should  be  synchronous  ;  as  the  seminal  fluid  is  ejacu- 
lated from  the  penis  it  is,  if  not  actually  sucked  in  part  into  the 
uterine  cavity,  at  least  by  the  extrusion  and  retraction  of  the  mucous 
plug  of  the  cervix,  drawn  in  part  into  the  cervical  canal.  An 
absolutely  normal  mechanism,  however,  is  not  always  neces- 
sary to  impregnation,  though  a  lack  of  it  explains  some  cases  of 
sterility.  One  of  my  patients  bore  a  child  within  a  year  after 
marriage  and  then  remained  sterile  for  six  years.  During  the 
whole  of  this  time  she  did  not  once  experience  sexual  excite- 
ment during  intercourse.  Finally,  for  the  first  time  in  six  years 
there  was  an  orgasm,  and  it  was  synchronous  with  the  husband's. 
This  coitus  proved  fruitful.  The  resultant  pregnancy,  curiously 
enough,  was  tubal.  There  are  many  women  who  have  abso- 
lutely no  sexual  feeling  and  who  never  experience  an  orgasm, 
but  who,  nevertheless,  become  pregnant  repeatedly.  Insemination 
has  occurred  also  when  the  woman  was  asleep,  drunk,  asphyx- 
iated, or  unconscious  from  some  other  cause.  These  cases  are 
explained  by  the  deposition  of  semen  in  the  vault  of  the  vagina, 
in  what  is  called  the  seminal  lake,  into  which  the  cervix  projects. 
The  spermatozoa,  attracted  by  the  alkalinity  of  the  cervical 
mucus  and  repelled  by  the  acidity  of  the  vaginal  secretions, 
make  their  way  through  the  cervical  canal  into  the  uterus.  This 
explanation  presupposes  a  normal  position  of  the  uterus.  A 
retroverted  uterus,  therefore,  with  the  cervix  tilted  so  far  for- 
ward  that   it   is    not  bathed  in   the  seminal   lake,   is  often,   but 

1  See  Janke,  "  Hervorbringung  des  GeschleclUs,"  Berlin  and  Leipsic,  1887. 


72 


PREGNANCY. 


not  necessarily,  a  bar  to  conception.  The  motility  of  the  sperm- 
atozoa enables  them  to  penetrate  the  canal,  although  it  may- 
be difficult  of  access.  Retroversion,  however,  is  a  cause  of 
sterility.  One  of  my  patients  bore  a  child  and  was  sterile 
for  five  years  afterward.  On  examining  her  to  discover  the 
cause  of  her  sterility,  I  found  a  complete  retroversion.  The 
malposition  was  corrected  and  the  uterus  was  supported  with 
a  pessary.  In  the  next  six  years  that  woman  bore  five 
children.  The  motility  of  the  spermatozoa  accounts,  too,  for 
the  cases  of  conception  without  insemination  at  all, — ^that  is, 
after  a  mere  deposition  of  seminal  fluid  upon  the  external 
genitals.  I  have  attended  in  confinement  two  married  women 
with  unruptured  hymens,  and  on  one  occasion  examined  a  young, 
unmarried  girl  with  a  perfectly  intact,  though  delicate  hymen, 
who  had  been  impregnated,  during  an  embrace  by  her  lover  in  the 
erect  posture,  from  the  deposition  of  semen  upon  the  labia 
majora. 

The  Meeting  Place  of  Ovule  and  Spermatic  Particle. — It 
is  generally  assumed  that  the  spermatozoa  meet  the  ovule  in  the 
ampulla  of  the  tube.      That  this  may  be  the  meeting  place  is 


Fig.  60. — Portions  of  the  ova  of  Asterias  glacialis,  showing  the  approach  and 
fusion  of  the  spermatozoon  with  the  ovum  :  a,  Fertilizing  male  element ;  b,  elevation 
of  protoplasm  of  egg  ;  b' ,  b" ,  stages  of  fusion  of  the  head  of  the  spermatozoon  with 
the  ovum  (Hertwig). 


proved  by  cases  of  tubal  pregnancy.  There  are  arguments, 
however,  in  favor  of  the  fundus  uteri  as  the  normal  meeting  place 
of  spermatic  particle  and  ovule.  If  ovulation  occurs  at  the  height 
of  menstrual  congestion,  the  ovule  has  probably  reached  the 
uterine  cavity  before  the  fruitful  coitus  occurs.  HyrtP  found  the 
ovule  in  the  uterine  extremity  of  the  tube  in  a  girl  who  had  died  on 
the  fourth  day  of  menstruation.  In  Jewesses,  who  are  prover- 
bially prolific,  copulation  is  not  allowed  until  a  week  after  the 
cessation  of  menstruation.     It  is  almost  inconceivable  that  the 

1  Miiller's  "  Handbuch,"  vol.  i,  p.  151. 


PLATE  I. 

26.  Two  ova  with  surrounding  membrana  granulosa  in  the  Fallopian  tube. 

27.  The  spermatozoon,  having  entered  the  ovum,  the  head  is  swollen. 

28.  0%aim  in  dyaster  stage  of  mitosis  for  first  polar  body. 

29.  The  second  polar  spindle,  placed  obliquely.     Chromosomes  undivided.     The 

polar  body  with  some  chromosomes,  discharged. 

30.  Dispirem  stage  of  the  second  polar  mitosis  mth  mid-body  in  central  spindle. 

31.  ONoim  with  pronucleus. 

32.  Ovum  with  pronucleus;  large  nucleolus  in  sperm  nucleus. 
^^.  Chromosomes  forming  in  the  pronuclei. 

34.  The  spirem  with  centrosome. 

35.  Ovum  with  first  segmentation-mitosis. 

36.  Ovum  in  dyaster  stage  of  the  first  segmentation-mitosis. 

37.  Ovum  in  dispirem  stage  of  the  first  segmentation-mitosis. 

38.  Ovum  with  twelve  segmentation-spheres  (blastomeres);  mitosis  in  two  of  them. 

39.  Unimpregnated  ovum  in  the  Fallopian  tube  on  the  third  day  after  ovulation. 

Cks,   Chromosomes;  ek,  nucleus;  rk ,  rk^,    rk^,    polar   bodies;   schw,  tail  of 
a  spermatozoon;  spk,  sperm-nucleus  (Sobotta). 


Plate  i. 


26.         _...-- 

27. 

'a 

/"'" 

-<-     ^^ 

V'.. 

c^s 

-Spk- 


29. 

rk.-- 


30. 


1   ^^ 


'<J(      > 


.V     t 


S     ^ 


X^^ 

■3?^      K:^!' 


3«. 


■  ■-.;■    ■"''  >u?  \'' . 


INSEMINA  TION. 


73 


ovum  has  not  reached  the  uterine  cavity  by  this  time.  It  is, 
however,  a  disputed  point  whether  the  impregnated  ovum  dates 
from  the  last  or  the  expected  and  missed  period.  The  question 
is  not  yet  decided,  and  the  student  is  at  hberty  to  adopt  the  view 
most  acceptable  to  his  reason.  My  own  belief  is  that  it  is  not  the 
ovum  of  the  last  period  which  is  impregnated. 

The  Fertilization  of  the  Ovum. — From  what  has  been  seen 
in  the  lower  animals  and  in  the  vegetable  kingdom,  it  is  probable 
that  the  ovum,  during  its  passage  through  the  tube  or  on  its  arrival 


Fig.  6i. — A,  Fertilized  ova  of  echinus  :  The  male,  a,  and  the  female  pronucleus, 
b,  are  approaching;  in  B,  they  have  almost  fused;  C,  ovum  of  echinus  after  com- 
pletion of  fertilization  ;  s.ti.,  segmentation-nucleus  (Hertwig). 


in  the  uterine  cavity,  excretes  some  material  which  attracts  the 
spermatic  particles,  as  the  female  elements  of  some  plants  attract 
the  male  elements  by  an  excretion  of  malic  acid.  From  the 
.swarm  of  spermatozoa  around  it  a  number  may  penetrate  the 
cell- wall  of  the  ovum,  but  only  one,  as  a  rule,  penetrates  the 
cell-contents.  From  what  is  seen  in  sea-urchins  it  is  claimed 
that  two  or  more  spermatozoa  may  enter  the  ovum  through  tiic 
same  opening  in  the  cell  periphery,  especially  if  it  is  immature  or 
atrophic,  and   that  thus   multiple  pregnancy   may   result.      The 


74 


PREG^'A.VCY. 


female  pronucleus  divides  into  as  many  portions  as  there  are 
male  pronuclei.  The  mechanism  of  ovular  penetration  is  as 
follows :  the  head  of  the  spermatozoon  fuses  with  a  pro- 
jection from  the  protoplasm  of  the  ovum  ;  the  tail  disappears. 
The  head  then  penetrates  the  cell-contents  and  becomes  the 
male  pronucleus, — a  small,  oval  body  (containing  the  chro- 
matin of  the  male  cell)  with  a  striated  arrangement  of  cell- 
contents  about  it  derived  from  the  centrosome.  Finalh-,  the 
male  pronucleus  unites  with  the  female  pronucleus.  Conception 
occurs  at  the  moment  of  this  union,  and  from  this  instant  dates 
the  life-beginning  of  the  future  embrvo,  fetus,  and  infant. 


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Figs.  62  and  63. — Curves  showing  relative  frequency  of  conception  following  coitus 
at  different  times  in  relation  to  menstruation.  In  both  diagrams  the  divisions  on  the 
abscissa  line  correspond  to  days  :  in  the  first,  to  days  after  the  onset  of  menstruation  ; 
in  the  second,  to  days  after  the  cessation  of  menstruation.  The  curves  indicate  the 
proportion  of  conceptions  to  copulations  on  each  day  of  the  menstrual  month  (Hensen). 

The  Time  when  Coitus  is  Most  Likely  to  Result  in  Con= 
ception.  —  Statistical  studies  show  that  impregnation  is  most 
likely  to  occur  after  copulation  during  the  first  eight  days  suc- 
ceeding the  cessation  of  menstruation.  There  is  a  period,  begin- 
ning fourteen  days  after  the  cessation  of  menstruation  and  lasting 
for  a  week,  during  which  coitus  is  least  likely  to  be  followed  by 
conception.  Some  women  claim  that  they  can  avoid  impregnation 
or  become  pregnant  at  will,  by  following  or  disregarding  this  rule. 


THE    CAUSES  AND    TREATMENT  OF  STERILITY.  75 

As  any  woman,  however,  may  ovulate  at  any  time  during  the  in- 
termenstrual period,  and  as  spermatozoa  may  retain  their  vitality 
for  more  than  three  weeks  in  the  Fallopian  tubes,  this  method 
of  preventing  conception  is  by  no  means  invariably  reliable. 

The  Average  Date  of  Conception  after  Marriage. — Nor 
mally,  impregnation  should  succeed  the  first  menstruation  fol- 
lowing marriage,  but  marriages  are  only  called  sterile  after  eighteen 
months  have  elapsed  without  conception.  Pregnancy  is  possible, 
however,  after  years  of  sterility.  The  author  has  had  charge  of 
women  who  conceived  for  the  first  time  nine,  thirteen,  and  twenty- 
four  years  after  marriage. 

THE   CAUSES   AND  TREATMENT  OF  STERILITY. 

In  at  least  20  per  cent,  of  sterile  marriages  the  fault  lies  with 
the  male.  His  spermatozoa  should  be  examined  under  the  micro- 
scope and  his  potentia  coeundi  should  be  ascertained  in  e\'ery  case 
as  part  of  the  routine  investigation  of  sterility  in  the  female.  The 
causes  of  sterility  in  the  wife  may  be  classified  as  follows: 

Anatomical  or  developmental  defects  preventing  normal  insemi- 
nation or  presenting  mechanical  obstacles  to  the  access  of  the  sper- 
matozoa to  the  ovum.  Atresia  or  stenosis  of  any  part  of  the  genital 
tract,  absence  or  arrested  development  of  the  ovaries  may  pre\-ent 
impregnation.  The  commonest  de\'elopment  anomaly  responsible 
for  sterility  is  stenosis  of  the  cervical  canal  and  a  U-shaped  ante- 
flexion of  the  uterus. 

Diseases,  injuries,  and  displacements  of  the  vulva,  such  as 
vaginismus,  kraurosis,  and  neoplasms  may  prevent  normal  in- 
semination, and  are  usually,  but  not  necessarily,  a  bar  to  conception, 
the  mere  deposition  of  semen  upon  the  external  genitals  being  fol- 
lowed sometimes  by  impregnation.  An  injury  of  the  vulva  wliich 
the  author  has  twice  seen  responsible  for  sterility  is  a  perforation 
of  the  fc3sa  navicularis  into  the  rectum  at  the  first  coitus,  the  hymen 
remaining  intact.  Subsequent  intercourse  occurred  by  way  of 
the  fistula. 

Stenosis  of  the  vagina  may  prevent  conception.  In  a  case  of 
the  author's,  howe\'er,  with  the  vagina  reduced  by  acquired  stenosis 
to  a  narrow  sinus  throughout  its  whole  length,  barely  admitting 
a  surgeon's  probe,  impregnation  occurred  by  the  deposition  of 
semen  upon  the  vulva.  Coitus  in  such  cases  has  not  infrequently 
been  practised  by  the  urethra,  which  has  been  gradually  dilated. 
With  a  coincident  vesicovaginal  fistula  above  the  site  of  complete 
atresia  impregnation  is  possible  and  has  occurred.  Injury  of 
the  pelvic  floor,  destruction  of  the  perineum,  inversion  of  the 
vagina,  may  be  causes  of  sterility  by  preventing  the  retention  of 
seminal  fluid. 


y^  PREGNANCY. 

Retroversion  of  the  uterus  may  be,  but  is  by  no  means  neces- 
sarily, a  cause  of  sterility.  In  the  supine  position  the  cervix  is 
tilted  upward  and  is  not  bathed  as  it  should  be  in  the  seminal 
lake  occupying  the  posterior  vault  of  the  vagina.  The  motility 
of  the  spermatozoa  may  overcome  the  obstacle,  but  cases  of  sterility 
are  cured  sometimes  by  a  pessary  or  the  operative  treatment  of 
retroversion. 

A  complete  prolapse  of  the  uterus  usually  prevents  conception, 
but  in  a  case  of  the  author's  impregnation  took  place  in  spite  of 
a  total  prolapse  of  years'  duration.  A  fibromyoma  or  other  neo- 
plasm of  the  uterus  or  of  the  endometrium  may  prevent  conception 
by  opposing  obstacles  to  the  ascent  of  the  spermatozoa,  but  the 
m.otility  of  the  latter  may  enable  them,  to  surmount  barriers  moun- 
tains high  in  comparison  with  their  microscopical  size  and  to 
traverse  ihe  most  tortuous  canal. 

Endometritis  with  a  profuse  mucopurulent  leukorrhea  may 
prevent  conception,  but  there  is  often  an  associated  salpingitis 
which  is  the  real  bar  to  impregnation.  An  intensely  acid  dis- 
charge from  the  cervix  may  be  inimical  to  the  activity  or  the  exist- 
ence of  the  spermatozoa. 

The  commonest  disease  of  the  genitalia  accountable  for  steril- 
ity is  salpingitis,  with  closure  of  the  abdominal  ostium  by  adhesive 
inflammation.  The  common  cases  of  "one-child  sterility"  are 
usually  due  to  this  cause,  and  it  also  explains  the  infrequency  of 
conception  in  prostitutes.  Diseases  and  neoplasms  of  the  ovaries, 
destroying  them  as  egg-producing  glands,  their  inclosure  in  an 
adventitia  of  inflammatory  exudate,  and  a  thickening  of  the 
proper  capsule,  prevent  ovulation  and,  therefore,  preclude  con- 
ception. 

Anemia  and  w^asting  diseases  may  deprive  the  Graafian  follicles 
of  the  blood  required  for  their  rhaturation  and  rupture  and  so  may 
prevent  ovulation. 

The  Psychic  Causes  of  Sterility. — It  is  true  that  women  may 
be  impregnated  while  asleep,  drunk,  asphyxiated,  or  unconscious 
from  any  cause  ;  by  the  mere  deposition  of  semen  upon  the 
external  genitalia;  by  the  artificial  injection  of  seminal  fluid  into 
the  genitalia;  without  ever  experiencing  the  least  sexual  sensation. 
Nevertheless,  a  lack  of  affinity  between  the  man  and  woman,  an 
absence  of  sexual  passion  and  of  an  orgasm,  may  account  for 
sterility. 

Treatment. — It  is  obvious  that  the  treatment  must  be  directed 
to  the  cause  and  must  vary  greatly  in  individual  cases.  A  careful 
study  of  the  patient  should  naturally  precede  the  treatment.  The 
case  may  call  for  the  removal  of  tumors  from  the  vulva;  the  cure, 
if  possible,  of  kraurosis;  the  gradual  dilatation  of  the  introitus 


THE    CAUSES  AND    TREATMENT  OF  STERILITY.  yj 

vaginae;  the  destruction  of  sensitive  papilla  around  the  vaginal 
introitus  by  the  electro-cautery  needle,  or  cutting  the  levator  ani 
muscles  in  vaginismus;  the  correction  of  atresia  or  stenosis  in  the 
genital  canal;  the  excision  of  the  hymen  and  the  closure  of  fistulas; 
the  repair  of  vaginal  injuries,  or  the  reposition  of  a  displaced  uterus. 
A  thorough  dilatation  of  the  cervical  canal  cures  more  cases  of 
sterility  than  any  other  single  procedure.  The  most  efficient  and 
permanent  dilatation  of  the  cervix  is  effected  by  the  author's  modi- 
fication of  Schatz's  metranoikter  (see  p.  789).  The  restoration  of 
patency  in  the  tubes  stands  next  in  order  of  efficiency  among  the 
operations  for  sterility  (see  p.  909) .  The  assumption  of  the  knee- 
chest  posture  after  coitus  may  be  recommended.  A  tonic  treat- 
ment for  anemia  may  be  indicated.  An  improvement  of  general 
health  and  strength  by  travel,  open-air  exercise,  and  a  generous 
diet  will  sometimes  be  successful  when  local  treatment  has  failed. 
Experiments  upon  the  lower  animals,  as  well  as  upon  human  beings, 
have  demonstrated  the  possibility  of  transplanting  the  ovary  to 
some  other  situation  than  its  normal  one  in  the  peritoneal  cavity, 
or  even  of  implanting  the  ovary  recently  removed  from  another 
person  with  continued  functional  activity  and  a  subsequent  con- 
ception. 

A  myomectomy  or  the  removal  of  any  pelvic  or  abdominal 
tumor  exerting  pressure  upon  the  genital  canal  may  prove  the  ob- 
stacle to  conception.^  If  there  is  uterine  or  cervical  leukorrhea, 
a  curettage  and  applications  of  antiseptics  or  astringents  to  the 
endometrium  are  indicated.  If  the  uterine  discharge  is  intensely 
acid,  it  is  claimed  that  intra-uterine  applications  of  milk  of  magnesia 
shortly  before  coitus  make  conception  possible. 

A  gouty  diathesis  sometimes  associated  with  this  acid  dis- 
charge should  be  treated  appropriately.  From  their  nature 
many  cases  are  incurable.  Occasionally  a  marriage  sterile  for 
many  years  may  inexpHcably  prove  fruitful  without  special  treat- 
ment. The  author  has  had  under  his  charge  in  confinement  a 
woman  who  conceived  for  the  first  time  after  more  than  twenty 
years  of  married  life,  when  she  had  given  up  all  ho])e  of  such  an 
event.  The  physician  should  usually  be  careful  not  to  inform 
his  patient  bluntly  that  she  is  hopelessly  sterile.  She  should  be 
allowed  to  entertain  some  hope  of  maternity  until  the  lapse  of 
years  has  reconciled  her  to  the  idea  that  she  can  not  expect  off- 
spring. 

1  In  a  case  of  sterility  of  tiiirteen  years'  duration  I  removed  5  myuniata  by  myo- 
mectomy.     Impregnation  occurred  in  tliree  montiis. 


78 


PREGNANCY. 


Fig.  64. — Diagrammatic  section 
of  a  mammalian  blastoderm  after  the 
cover-cells  have  completely  closed  in 
the  blastoderm,  and  the  embryo  proper 
has  become  two-layered:  ep' ,  Non-em- 
bryonic epiblast ;  ep,  embryonic  epi- 
blast ;  ky,  hypoblast ;  ys,  yolk-sac 
(from  Haddon). 


CHANGES  IN  THE  OVUM  FOLLOWING  IMPREGNATION.  ^ 

Directly  after  the  formation  of  the  nucleus  of  segmentation  by 

the  fusion   of  male  and  female  pronucleus  the  ovum  begins  to 

segment.  The  original  mass  di- 
vides itself  into  two  cells  (blasto- 
meres),  these  into  four,  and  so  on 
until  the  whole  ovum  is  sur- 
rounded by  a  layer  of  cells  inclos- 
ing a  group  of  somewhat  larger 
cells  (morula,  or  mulberry  mass), 
and  a  hollow  cavity  containing 
albuminous  fluid.  This  stage  of 
development  is  called  the  blastula, 
or  blastodermic  vesicle.  The  cells 
of  the  ovum  next  arrange  them- 
selves into  a  thinned-out,  lami- 
nated layer  around  the  periphery 
of  the  ovum,  and  another  layer 
just  within  this,  the  offspring    of 

the  central   mass  •  of   cells  (the  ectoderm),  and  the  proliferating 

central    mass    itself,  —  the 

entoderm.      Regarding  the 

surface    of  the    ovum,    an 

oval,    opaque    region    may 

be  observed  (the  embryonal 

area),  and  in  the  middle  of 

this  area  a  streak  of  greater 

opacityappears, — the  prim- 
itive streak.      At  the  site  of 

this     streak    a    depression 

next  appears, — the  prim- 
itive groove.  A  microscopic 

examination    of    a   section 

through    this    region    now 

shows  the  development  of 

a  median  layer  of  cells  (the 

mesoderm),    made    up     of 

cells  derived  in  part  from  a 

layer  furnished  by  the  ecto- 
derm and  by  another  fur- 


_     Head- 
process. 


/ 


Fig.  65. — Embryonic  area  of  rabbit  em- 
bryo :  Primitive  streak  beginning  in  cell- 
proliferation,  known  as  the  "  node  of  Hensen  " 
(E.  V.  Beneden). 


^  It  is  not  intended  to  give  more  than  a  mere  sketch  of  the  development  of  the 
embryo.  The  student  interested  in  the  subject  is  referred  to  special  works,  such  as 
Minot's  "  Embryology." 


Plate  2. 


Outer  cell.  ^"'^''  ""^ 


Outer 

cells 


I,  2.  3.  Diagrams  illustraliiiL;;  tlie  seijmrntation  of  tlie  mammalian  oviim  (Allon 
Tliomson.  after  van  lifiicdeni.  4,  I)iaL;raiii  illiistratint;  tlie  rclalioii  of  llic  primary 
layers  of  the  blastoderm,  the  segmentation-cavity  of  this  stage  corre-.])nn<ling  with 
the  archenteron  of  amj)hio\us  (iJonnet). 


CHANGES  IN  OVUM  FOLLOWING  IMPREGNATION. 


79 


nished  by  the  entoderm.  In  the  course  of  its  development 
the  mesoderm  develops  lateral  reduplications  and  parts  into 
two  layers  (the  parietal  and  visceral  layers)  inclosing  spaces, — 
the  body-cavity,  or  celom  (Fig.  66).  The  parietal  or  somatic 
layer  unites  with  the  ectoderm  to  form  the  somatopleure.      The 


Primitive  groove. 


Beginning 

amnion  fold. 


Ectoderm. 


Visceral  layer 

of  ■mesoderm.  Entoderm. 

Fig.  66. — Transverse  section  of  the  embryonic  area  of  a  fourteen-and-a-half-day  ovum 

of  sheep  (Bonnet). 


Axial  zone.  ,  Neural  canal. 


Lateral  plates  for 

body-ivalls. 


Lateral  plates  for 
gut-tract. 


Lateral  zone 


Cavity  wit/tin  somite. 


Parietal  mesoderm. 


Pleuroperitontal 
cavity. 


Vitelline  vein. 
Fig.  67. — Transverse  section  of  a  seventeen-and-a-balf-day  sheep  embryo  (Bonnet). 


visceral  or  splanchnic  layer  joins  the  entoderm  to  form  the 
splanchnopleure.  At  the  end  of  the  second  week  the  de- 
velopment of  the  embryo  proper  begins,  by  the  formation  of 
the  neural  folds,  the  neural  canal,  the  chorda  dor.salis,  or 
notochord,  and  the  somites,  or  provertebrae.  The  normal  de- 
velopment of  the  embryonal  body  now  depends,  in  its  gross 
features,   upon   an   arching-ovcr  process  of   cells  which   inclose 


8o  PREGNANCY. 

the  spinal  canal,  the  abdominal  and  thoracic  cavities,  and  the 
cranial  cavity.  An  arrest  in  these  developmental  processes  re- 
sults in  such  deformities  as  spina  bifida,  exomphalos,  celosoma, 
hydrencephalocele,  and  anencephalia. 

Assuming  that  impregnation  occurs  in  the  ampulla  of  the  tube, 
some  five  to  seven  days  elapse  before  the  ovum  arrives  in  the 
uterine  cavity.  The  implantation  of  the  ovum  in  the  uterine 
mucous  membrane  occurs  in  the  following  manner:  Either  by 
pressure  or  by  an  active  erosion  of  the  uterine  cells  by  the  primitive 
peripheral  cells  of  the  ovum  the  epithelium  of  the  endometrium 
is  penetrated,  and  the  o\^m  imbeds  itself  in  the  connective  tissue 
of  the  mucosa,  the  epithelium  closing  over  it  again  and  thus  ex- 
cluding it  from  the  uterine  cavity  (Peters), 


CHAPTER    III. 
The  Development  of  the  Embryo  and  Fettfs. 

The  changes  in  the  developing  embryo  and  fetus  ^  from 
month  to  month  have  practical  value  for  the  obstetrician  w^hen 
he  would  determine  the  probable  date  of  impregnation  from  the 
appearance  of  the  cast-off  ovum.  The  intelligent  explanation  of 
many  congenital  deformities  and  intra-uterine  accidents  and  dis- 
eases also  depends  upon  a  knowledge  of  intra-uterine  develop- 
ment. 

First  Month. — Direct  observation  of  the  human  ovum  dur- 
ing and  shortly  after  impregnation  fails  us.  The  theories  as 
to  the  site  in  which  this  phenomenon  occurs,  as  to  the  changes 
that  immediately  succeed  it,  are  based  upon  what  has  been 
actually"  seen  in  the  lower  animals,  and  upon  the  clinical  history 
of  pregnancies  in  which  the  ovum  is  developed  in  an  unnatural 
situation.  Thus  it  is  argued  that  the  spermatic  particle  must 
penetrate  the  ovule  shortly  after  its  escape  from  the  Graafian  fol- 
licle, for  the  occasional  occurrence  of  abdominal  and  tubal  preg- 
nancies proves  that  the  spermatozoa  can  make  their  way  far  into 
the  tube  and  even  on  to  the  surface  of  the  ovary  ;  and  what  is 
seen  in  animals  makes  it  probable  at  least  that  the  outer  coating 
of  the  ovule,  during  its  passage  through  the  tube,  receives  an  ad- 
ditional thickness  from  an  albuminous  deposit  upon  it,  or  that 
the  original  cell-wall  becomes  denser  and  tougher  by  a  process 

^  The  usual  plan  of  calling  the  product  of  conception  "embryo"  for  the  first 
three  months,  and  afterward  "  fetus,"  is  the  one  adopted  here. 


DEVELOPMENT  OF  THE  EMBRYO  AND  FETUS.  8 1 

of  coagulation  ;  either  of  which  conditions  would  render  the 
penetration  of  the  ov^ule  by  a  spermatic  particle  unlikely,  if  not 
impossible.  On  the  other  hand,  it  is  claimed  ^  that  if  the  ovule 
escapes  from  the  ovary  at  the  beginning  of  the  menstrual  flow, 
and  if  the  fruitful  coition  occurs  only  some  days  after  menstru- 
ation has  ceased,  as  is  common  at  least  among  civilized  people, 
the  time  that  intervenes  between  the  rupture  of  the  Graafian 
follicle  and  the  deposition  of  semen  in  the  female  genital  tract 
has  been  too  great  for  the  ovule  to  remain  in  the  ovarian  ex- 
tremity of  the  oviduct,  but,  on  the  contrary,  insures  its  presence 
in  the  uterine  cavity.  It  is  asserted  that  the  rhythmical  contrac- 
tion of  the  muscles  in  the  tubal  walls  which  drives  the  exuded 
menstrual  blood,  as  well  as  the  ovule,  toward  the  uterus,  offers 
an  additional  barrier  to  the  ascent  of  the  spermatozoids.  This 
argument  is  invalidated,  however,  by  the  occasional  occurrence 
of  extra-uterine  pregnanc}\  The  old  explanation  of  the  migra- 
tion of  the  ovum  to  the  abdominal  orifice  of  the  tube  was  that 
the  fimbriated  extremity  of  the  latter  became  "erected"  at  the 
time  the  ovule  escaped,  and  grasped  with  its  fimbrise  the  sur- 
face of  the  ovary,  thus  displaying  a  sort  of  independent  in- 
telligence. The  anatomical  impossibility  of  the  fimbriae  being 
closely  and  accurately  applied  to  the  surface  of  the  ovary 
has  been  demonstrated,  ^  and  the  tube  contains  no  true  erec- 
tile tissue  ;  this  theory,  therefore,  has  long  been  exploded. 
The  fact  that  the  fimbriae  are  provided  with  ciliated  epithe- 
lial cells  which  work  actively  toward  the  uterus,  and  create  a 
stream  in  the  moisture  which  is  always  present  upon  the 
peritoneal  surface,  accounts  for  the  transference  of  the  ovule  from 
the  ovary  to  the  oviduct.  The  ovule,  being  discharged  from  the 
Graafian  follicle,  is  either  brought  directly  in  contact  with  the 
cilia  of  a  fimbria,  or  else,  dropping  upon  the  peritoneum,  it  is 
caught  in  the  gentle  current  of  a  minute  quantity  of  fluid  that 
always  bathes  that  membrane,  and  is  so  conveyed  to  the  wide 
opening  of  the  abdominal  end  of  the  oviduct.  This  explanation 
also  accounts  for  the  so-called  "external  migration"  of  the 
ovule,  which,  discharged  from  an  ovary  and  failing  for  some 
reason  to  be  taken  up  by  the  corresponding  tube,  finds  its  way 
to  the  opposite  tube, — an  occurrence  that  has  been  observed  in 
certain  cases  of  tubal  pregnancy.^ 

1  See  Wyder:  "  Beitr.  zur  Lehre  v.  d.  Extrauterinschwangerschaft  u.  dam  Oite 
der  Zusammentreffens  von  Ovulum  u.  Spermatozoen,"  "  Archiv  f.  Gyn.,"  Bd.  x.xviii, 

s.  325- 

2  Henle,  "  Handb.    Anat.   d.    Menschen,"    1864,    Bd.  ii,  S.  470;  and   Bisclioft", 
"  Entwickelungsgeschichte,"  S.  28. 

^  Wyder,  loc.  cit. 
6 


82 


PREGNANCY. 


DEVELOPMENT  OF  THE  EMBRYO  AND  FETUS.  "^i 

The  changes  in  the  ovum  immediately  before  impregnation 
are  described  in  the  preceding  chapter.  It  only  remains  to 
notice  the  successive  changes  in  size  and  development  that 
determine  the  age  of  the  ovum  and  embryo  and  that  explain 
intra-uterine  deformities  and  diseases. 

The  youngest  human  ova  seen  and  described  have  been 
eight  to  thirteen  days  old.^  Peters'  claim  that  the  o\aim  in  his 
famous  case  was  only  three  or  four  days  old  is  not  generally 
admitted.  In  this  case  the  diameter  of  the  ovum  was  about  i 
mm.;  the  chorion  is  furnished  with  thin  and  simple  villi,  the 
allantois  is  not  to  be  detected,  and  almost  the  whole  ovum  is 
occupied  by  the  yolk-sac. 

Waldeyer  has  described  an  ovum,  twenty-eight  to  thirty 
days  old,  that  measured  19  mm.  (0.748  in.)  in  length,  16.5  mm. 
(0.649  in.)  in  breadth  (about  the  size  of  a  pigeon's  &%%),  and 
weighed  2.3  gm.  (36  grs.).  The  length  of  the  embryo,  in  a 
straight  line  from  cephalic  to  caudal  extremity,  was  8  mm. 
(0.315  in.),  while  the  actual  length  of  the  dorsal  line  was 
20  mm.  (0.79  in.). 

During  the  first  month  the  human  embryo  is  indistinguish- 
able from  that  of  other  mammals.  The  ovum  at  this  early 
period  may  be  described  as  a  double-walled,  flattened  vesicle, 
filled  with  fluid.  The  outer  wall  bears  the  branched  villi ;  the 
inner  one  is  smooth.  The  connection  of  the  villi  with  the 
decidua  reflexa,  and  even  with  the  decidua  serotina,  is  a  super- 
ficial one,  and  the  ovum  is  easily  separated  from  its  uterine 
attachments.^  The  yolk-sac,  at  first  occupying  nearly  the 
whole  ovum,  even  at  the  end  of  the  first  month  is  larger  than 
the  cephalic  extremity  of  the  embryo.  The  visceral  arches 
are  distinct  ;  the  limbs  are  merely  rudimentary ;  the  cord  is 
straight,  thick,  and  short ;  and  the  amnion  is  still  quite  close 
to  the  embryo,  and  is  separated  from  the  chorion  by  a  clear 
space. 

During  the  first  month  the  heart  appears  as  a  cylindrical 
body,  which  soon  becomes  S- shaped,  and  by  the  fourth 
week  displays  four  distinct  cavities  and  is  covered  by  its  peri- 
cardium. It  is  probably  functionally  active  by  the  third 
week.^     The   brain   and   spinal    cord   arc   inclosed;    the    inlcs- 

1  "  Edinb.  Med.  Jour.,"  vol.  lii ;  "  Verhandl.  d.  Ak.  d.  W.  Amsterdam,"  iii,  3 ; 
"Historic  du  Develop.,"  pi.  iii;  "Arch.  f.  Gyn.,"  Bd.  v,  S.  170;  "Ahhandl.  d. 
Konigl.  Ak.  d.  W.  zu  Berlin";  "  Wien.  med.  Wochen.,"  1877,8.  502;  "  Arcli. 
f.  Gyn.,"  Bd.  xii,  S.  421  ;  ibid.,  Bd.  xii,  S.  482;  Peters,  "  Ueber  die  Einbetlung 
des  Menschlichen  Eies,"  1899;  Leopold,  "  Centralbl.  f.  Gyn.,"  1896,  p.  1057;  also 
"  Uterus  u.  Kind." 

2  See  Br.  Hicks,  "  Obst.  Tr.,"  xiv,  p.  149;  Langhans,  "  Archiv  f.  An.  u. 
Phys.,"  1877,  ii  u.  iii,  S.  231  ;   Ahlfeld,  "Arch.  f.  Gyn.,"  Bd.  xiii,  S.  231. 

3  Preyer,  "Specielle  Physiologic  des  Embryos." 


84 


PREGNANCY. 


tinal  tract  is  also  closed  over,  but  the  connection  with  the 
umbilical  vesicle  is  still  a  wide  one ;  the  first  traces  of  a  liver 
appear  ;  the  primitive  kidneys  may  be  seen  ;  and  toward  the  end 
of  this  period  the  eyes  may  be  distinguished  at  the  sides  of  the 
head  and  the  rudimentary  extremities  become  visible  as  four  bud- 
like processes.  The  oral  and  anal  orifices  of  the  intestinal  tract 
are  formed  by  depressions  in  the  integuments,  which  open  into  the 
extremities  of  the  tract  after  the  absorption  and  disappearance  of 
the  intervening  tissues. 

Second  .Month.. — At  the  beginning  of  the  second  month  the 
-^'ovum  is  th^^size  of  a  pigeon's  ^gg,  and  the  embryo  measures 

-  8    mm.    (0.3   inch)  in  a 

straight  line  from  head  to 
tail.     During  this  month 
the  embryo  grows  to  2.5 
cm.  (i  in.)  in  length  and 
the    ovum    reaches    the 
size  of  a  hen's  &^^.   The 
visceral  clefts  close,  with 
the  exception  of  the  first, 
which  eventually  forms 
the     external     auditory 
meatus,  the  cavity  of  the 
t}'mpanum,  and  the  Eu- 
stachian tube.      The  first 
visceral     arch,    dividing 
into  two  branches,  forms 
the  superior  and  inferior 
maxillary      processes. 
The    latter,     one     from 
each  side,  approach  each 
other    and   finally   unite 
to  form  the  lower  jaw. 
The     superior     maxil- 
lary processes,  while  ap- 
proaching each  other,  are  kept   from  uniting  by  the  interven- 
tion of  the   frontal  process.      At   the  point  of  junction  of   the 
latter  with  the  two  superior   maxillary  processes  there  occurs 
occasionally    the    deformity    known    as    harelip,  from    the    fail- 
ure of  the  processes  to  unite  ;   but  as  union   is   always  perfect 
before  the  end  of  the  second  month,  the  arrest  of  development 
that   results   in   this  deformity  must   have  taken  place  at  some 
time   prior    to    the    third    month.      During   the   second   month, 
from  the  growth  of  the  viscera,  the  body  becomes  less  curved, 
and  from  the  development  of  the  brain  the  head   increases  in 


Fig.  69. — Human  en)bryo   of  about   six    weeks, 
enlarged  five  times  (His). 


DEVELOPMENT  OF  THE  EMBRYO  AND  FETUS.  85 

size.  The  umbilical  vesicle  atrophies,  and  may  be  found  at- 
tached to  the  body  by  a  slender  pedicle.  The  umbilical  ring 
is  somewhat  contracted,  but  still  contains  a  few  loops  of  intes- 
tine ;  so  that  if  there  is  at  this  time  an  arrest  in  the  develop- 
ment of  the  abdominal  walls,  an  extensive  umbilical  hernia 
or  exomphalos  results.  The  umbilical  cord  runs  straight  to 
the  periphery  of  the  ovum.  The  eyes  occupy  a  position  on  the 
sides  of  the  head  ;  behind  them  may  be  seen  the  ears,  and  in 
front  arises  the  external  nose.  The  limbs  are  separated  into 
their  three  divisions,  and  the  first  suggestions  of  hands  and  feet 
appear,  with  the  fingers-and  toes  webbed.  The  Wolffian  bodies 
are  much  lessened  in  size,  but  the  kidneys  and  suprarenal  cap- 
sules are  developed.  The  external  genitals  make  their  appear- 
ance, but  neither  internally  nor  externally  is  the  sex  to  be  dis- 
tinguished, for  the  elements  of  both  sexes  are  present  in  equal 
degree.  Toward  the  end  of  the  second  month  or  at  the  begin- 
ning of  the  third  the  eyelids  appear.  There  are  points  of  ossifi- 
cation to  be  seen  in  the  lower  jaw  and  clavicle.  The  villi  of  the 
chorion  have  taken  on  a  more  luxuriant  growth  at  the  point 
where  the  future  placenta  is  to  be  developed,  and  the  fetus  draws 
its  nutriment  from  the  maternal  blood. 

Third  Month. — During  this  month  the  ovum  attains  the 
size  of  a  goose's  &'g^,  9.5  to  1 1  cm.  (3.74  to  4.3  in.)  long,  and 
the  embryo  grows  to  a  length  of  7  to  9  cm.  (2.75  to  3.5  in.) 
and  weighs  about  30  gm.  (460  grs.).  The  umbilical  cord  in- 
creases in  length  to  7  cm.  (2.7  in.)  and  becomes  twisted.  The 
umbilical  ring  is  smaller  and  the  intestines  are  retracted  within 
the  abdomen.  The  fingers  and  toes  lose  their  webs,  and  the 
nails  appear  as  fine  membranes.  The  eyes  approach  nearer 
to  each  other  and  are  protected  by  the  lids.  Points  of  ossi- 
fication may  be  found  in  most  of  the  bones,  and  tiic  neck 
separates  the  head  from  the  trunk.  The  ribs  divide  the  trunk 
plainly  into  chest  and  abdomen  ;  the  oral  and  .nasal  cavities  are 
separated  by  the  palate  ;  the  lips  close  over  the  mouth  and  teeth 
begin  to  form  in  the  jaws.  The  sex  may  be  distinguished  by 
the  presence  or  absence  of  a  uterus  ;  cutaneous  folds  form  a 
scrotum  or  the  labia  majora,  but  the  clitoris  and  penis  are  still  of 
equal  length.  The  chorion  loses  its  villi,  except  at  the  point 
where  the  placenta  is  developing.  The  latter,  though  small, 
can  plainly  be  distinguished. 

Fourth  Month. — In  the  fourth  montli  the  fetus  attains  a 
length  of  10  to  17  cm.  (4  to  6.75  inches)  and  a  weight  of  55 
gm.  (850  grs.).  1      The   umbilical  cord  is  more  twisted   than  in 

1  Given  by  Spiegelberg  as  Hecker's  weights  and  measurements.  Spiegelberg, 
"  Lehrbuch,"  tr.  by  Syd.  Soc,  p.  1 18. 


86  PREGNANCY. 

the  preceding  month,  and  the  placenta  is  increased  in  size. 
The  head  of  the  fetus  now  amounts  to  a  quarter  of  the  whole 
length  of  the  body,  and  the  cranial  bones  are  in  part  ossi- 
fied, although  the  fontanels  and  sutures  gape  widely.  The  sex 
is  plainly  seen,  the  genital  fissure,  in  the  case  of  a  male,  hav- 
ing united  to  form  the  scrotum,  leaving  in  the  median  line  a 
distinct  raphe.  The  future  prostate  is  indicated  by  a  thickening 
at  the  point  of  meeting  of  the  genital  cord  and  the  urethra.  A 
fine  growth  of  down  appears  upon  the  fetal  skin  (lanugo),  and  a 
few  hairs  are  seen  on  the  scalp.  The  intestines  contain  meco- 
nium ;  the  limbs  may  be  feebly  moved  ;  and  the  fetus  may  live, 
if  born,  as  long  as  four  hours  (Cazeaux). 

Fifth  Month. — During  this  month  the  fetus  is  about  i8  to 
27  cm.  (7  to  10.5  inches)  long  and  weighs  about  273  gm.  (8 
ounces).  The  umbilical  cord  is  about  31  cm.  (12  inches)  long. 
The  liquor  amnii  exceeds  the  fetus  in  weight.  The  head 
is  relatively  very  large ;  the  face  has  a  senile  look  and  is 
wrinkled,  and  the  eyelids  begin  to  open.  The  skin  is  richer 
in  fat,  is  covered  with  lanugo,  and  in  places  with  vernix  case- 
osa,  a  sebaceous  material  containing  also  epithelial  scales  and 
downy  hairs.  Some  time  during  the  fifth  month  the  mother 
usually  experiences  "quickening," — that  is,  the  movements 
of  the  fetus, — and  the  fetal  heart-sounds  may  be  heard  on 
auscultation.  If  the  fetus  should  be  born  at  this  time,  it  may 
make  efforts  to  cry,  but  it  dies  in  a  few  hours. 

Sixth  Month. — The  fetus  toward  the  end  of  the  sixth  month 
is  from  28  to  34  cm.  (11  to  13.5  inches)  long  and  weighs 
676  gm.  {2T,y2  ounces).  The  skin  is  better  supplied  with  fat  ; 
the  hairs  of  the  scalp  grow  longer ;  eyebrows  and  eyelashes  are 
distinct.  The  umbilical  cord  is  inserted  in  the  middle  third, 
between  the  pubic  symphysis  and  the  xiphoid  cartilage.  The 
head  is  still  relatively  large.  The  testicles  in  boys  approach 
the  inguinal  rings.  If  a  fetus  at  this  stage  should  be  bom, 
it  might  live  from  one  to  fifteen  days,  but  would,  in  all 
probability,  eventually  die  from  insufficient  assimilation  of 
food,  from  rapid  loss  of  heat,  and  from  imperfect  respiration, 
owing  to  the  undeveloped  state  of  the  finer  ramifications^  of  the 
air-passages. 

Seventh  Month. — At  the  end  of  this  month  the  fetus 
measures  in  length  35  to  38  cm.  (13.75  to  15  inches)  and  weighs 
1 170  gm.  (41  ^  ounces).  The  whole  body  is  covered  with  lanugo 
except  the  palms  of  the  hands  and  the  soles  of  the  feet.  The 
large  intestine  contains  a  considerable  quantity  of  meconium. 
The  pupillary  membrane,  which  had  hitherto  obscured  the  pupil, 


DEVELOPMENT  OF  THE  EMBRYO  AND  FETUS.  8/ 

now  disappears.  A  child  born  between  the  twenty-fourth  and 
twenty-eighth  weeks  usually  dies.^ 

Eighth  Month. — The  fetus  measures  in  length  39  to  41 
cm.  (15.25  to  16  inches)  and  weighs  1571  gm.  (3^  pounds). 
The  hair  on  the  scalp  is  more  abundant ;  the  down  on  the  face 
is  disappearing.  One  of  the  testicles,  usually  the  left,  has  de- 
scended into  the  scrotum.  The  nails  are  firmer,  but  do  not  yet 
project  beyond  the  finger-tips.  At  the  end  of  the  eighth  month 
ossification  begins  in  the  lower  epiphysis  of  the  femur.  The  cord 
is  inserted  a  little  below  (0.6  to  1.2  inches)  the  middle  point, 
between  the  xiphoid  appendix  and  the  pubic  symphysis.  A  child 
born  at  this  period  may,  with  proper  care,  survive. 

Ninth  Month. — The  length  of  the  fetus  measures  42  to  44  cm. 
(16.5  to  17.25  inches)  and  the  weight  is  1942  gm.  (41^  pounds). 
There  is  a  decided  increase  in  subcutaneous  fat.  The  nails  are 
not  yet  perfectly  developed.  Toward  the  end  of  this  month, 
near  the  thirty-sixth  week,  the  weight  is  about  5^  pounds,  and 
the  diameters  of  the  skull  about  i  to  1.5  cm.  (0.39  to  0.50  in.) 
less  than  in  a  normal  fetus  at  term.^  The  bones  of  the  skull 
are  compressible  and  easily  molded  to  the  shape  of  the  pelvic 
cavity  ;  and  if  born  at  this  time,  the  infant  with  ordinary  care 
will  certainly  live. 

Tenth  Month. — During  the  tenth  month  (thirty-sixth  to  for- 
tieth week)  the  fetus  is  developing  from  the  condition  just  de- 
scribed— that  is,  characteristic  of  the  thirty-sixth  week — into 
the  infant  at  term,  distinguished  by  all  the  features  that  indicate 
the  arrival  of  the  fetus  at  maturity.  It  is  during  the  last  month 
of  pregnancy  that  the  physiology  of  the  fetus  can  be  studied  to 
the  best  advantage.  It  has  now  reached  a  large  size  and  requires 
a  considerable  quantity  of  oxygen^  for  its  blood  and  nourishment 

1  There  persists,  even  yet,  in  the  minds  of  some  general  practitioners,  as  well  as 
among  the  laity,  as  the  writer  can  testify,  the  idea  that  children  born  in  the  seventh 
month  will  be  more  likely  to  survive  than  those  born  at  the  eighth  month.  Professor 
Parvin  ("  Science  and  Art  of  Obstetrics  ")  shows  how  this  superstition  has  descended, 
through  more  than  two  thousand  years,  from  Hippocrates,  wlio  explained  that  the 
fetus  is  placed  with  its  head  uppermost  in  the  uterine  cavity  until  the  seventh  month, 
when  the  increasing  weight  of  the  head  causes  it  to  fall  down  to  the  03  uteri.  As 
soon  as  this  occurs,  the  fetus  attempts  to  make  its  escape,  and  if  it  is  strong  it  suc- 
ceeds, but  if  the  attempt  fails,  it  is  repeated  at  the  eighth  month,  and  if  the  infant 
now  succeeds  in  escaping  from  the  womb,  being  exhausted  by  its  previous  effort,  it  is 
likely  to  die. 

2  Schroeder,  from  the  measurements  of  68  premature  infants,  gives  the  average 
biparietal  diameter  of  the  head  as  8.83  cm.  (3.5  in.)  from  the  thirty-sixth  to  the 
fortieth  week;  8.69  cm.  (3.42  in.)  from  the  thirty-second  to  the  thirty-sixth  week; 
8.16  cm.  (3.21  in.)  from  the  twenty-eighth  to  the  thirty-second  week,  showing  that 
this  diameter,  a  most  important  one,  is  relatively  very  large  even  early  in  fetal  life. 

s  That  the  fetus  obtains  oxygen  from  the  maternal  blood  has  been  proved  by 
(i)  cutting  off  the  blood-supply  to  the  uterus,  when  the  fetus  will  die  of  asphyxia 
(Vesal,  Seyl)  ;  (2)  by  the  discovery,  by  means  of  spectral  analysis,  of  oxyhemoglobin 
in  the  umbilical  vein  of  the  cord  (Zweifel). 


88  PREGNANCY. 

for  its  tissues,  both  of  which  it  obtains  from  the  maternal  blood 
through  the  medium  of  the  epithelial  cells  that  form  the  outer- 
most fetal  layer  of  the  placenta  (the  syncytium).  From  the 
fact  that  the  fetus  undoubtedly  swallows  considerable  quantities 
of  liquor  amnii  during  the  latter  months,  at  least,  of  pregnancy,  ^ 
and  because  that  liquor  contains  a  small  proportion  of 
albumin, 2  it  has  been  claimed  that  the  fetus  derives  its 
whole  nourishment  from  the  amniotic  fluid,  while  the  func- 
tion of  the  placenta  is  confined  to  the  oxygenation  of  the 
fetal  blood, — a  theory  not  likely  to  find  general  acceptance. 
Another  fact,  however,  in  its  favor  is  the  secretion  of  the  gastric 
glands  during  the  latter  period  of  intra -uterine  life.^  The  urine, 
secreted  in  considerable  quantity,  and,  as  a  rule,  albuminous,* 
is  voided  freely  into  the  amniotic  cavity.  The  fetus,  from  time 
to  time,  moves  its  limbs  vigorously,  and  its  heart  beats  from 
one  hundred  and  twenty  to  one  hundred  and  sixty  times  a 
minute. 

The  circulation  of  the  fetal  blood  has  certain  peculiarities  that 
deserve  consideration.  Beginning  at  first  by  a  very  simple 
arrangement  in  a  tubular  heart  and  four  vessels  (two  arteries  and 
two  veins),  which  carry  the  blood  to  and  from  the  umbilical 
vesicle,  it  soon  assumes  the  characteristics  that  are  most  plainly 
to  be  seen  in  the  stage  of  pregnancy  under  consideration.  The  . 
blood  that  has  been  oxygenated  in  the  terminal  villi  of  the 
placental  tufts  is  returned  by  veins  of  increasing  size  to  the 
large  branches  of  the  umbilical  vein,  which  may  be  seen  directly 
under  the  amnion  on  the  fetal  surface  of  the  placenta.  These 
branches,  converging,  unite  in  the  umbilical  vein,  which  is  carried 
by  the  cord  to  the  fetal  body  at  the  umbilicus.  Thence 
it  runs  along  the  anterior  surface  of  the  abdominal  cavity  to 
the  under  surface  of  the  liver,  where,  giving  off  branches  to 
the  lobus  quadratus,'  lobus  Spigelii,  and  to  the  left  lobe,  it 
divides  into  two  main  trunks  at  the  transverse  fissure,  the  larger 
of  which  enters  the  portal  vein,  while  the  other  empties  into  the 
ascending  cava  and  is  called  the  ductus  venosus.  Thus  by  far 
the  greatest  quantity  of  oxygenated  blood  that  is  returned  to  the 
fetus  from  the  placenta  must  first  pass  through  the  liver  before 
entering  the  general  circulation.     The  ascending  cava  conveys 

^  Zweifel,  "  Untersuchungen  iiber  das  Meconium,"  "Arch.  f.  Gyn.,"  Bd.  vii,  1875, 
P-  474- 

2  Anderson,  "Am.  Jour.  Obstetrics,"  Aug.,  1884. 

3  Krukenberg,  "  Magensecretion  des  Fotus,"  "  Centralbl.  f.  Gyn.,"  No.  22,  1884. 
*  Ribbert,  "  Ueber   Albuminuric  des    Neugeboren   u.    des    Fotus,"   Virchow's 

Archiv,"  Bd.  xcviii,  S.  527. 


DEVELOPMENT  OF  THE  EMBRYO  AND  FETUS. 


89 


t:h 


then  to  the  right  auricle  a  large  proportion  of  arterial  blood,  but 
mixed  with  it  is  the  venous  blood  from  the  lower  extremities  and 
the  blood  returned  from  the  liver.  But  this  great  volume  of 
blood  having  arrived  at  the  right  auricle,  instead  of  descending 
into  the  right  ventricle  and 
being  carried  thence  to  the 
lungs,  which  in  their  unex- 
panded  condition  could  not 
contain  it,  is  guided  across 
the  right  auricle  by  the  Eus- 
tachian valve,  and  enters  the 
left  auricle  by  means  of  an 
opening  in  the  interauricular 
septum, — the  foramen  ovale. 
From  the  left  auricle  the 
blood  from  the  ascending  cava 
enters  the  left  ventricle  and  is 
driven  thence  into  the  aorta, 
by  which  it  is  conveyed  pri- 
marily to  the  upper  extremity 
of  the  fetus  by  the  ascending 
branches  of  the  arch  of  the 
aorta.  Here  may  be  seen  an 
arrangement  peculiar  to  fetal 
life,  by  which  the  blood  is  di- 
verted from  the  unused  lungs 
and  conveyed  instead  to  the 
aorta.  Just  beyond  the  point 
at  which  these  branches  are 
given  off  there  opens  into  the 
aorta  a  large  branch  from  the 
pulmonary  artery  (the  ductus 
arteriosus),  which  conveys  the 
blood  that  enters  the  right 
auricle,  and  then  the  right 
ventricle,  from  the  descending 
vena  cava.  Only  a  small 
quantity  of  blood,  sufficient 
for  their  nutrition,  goes  to 
the    luncfs.      Thus    the    aorta 


Fig.  70. — Diagram  of  the  fetal  circu- 
lation :  a,  a,  Aorta;  b,  innominate  artery; 
c,  left  carotid ;  d,  left  subclavian;  e,  iliacs  ; 
f,  internal  iliac  arteries  ;  ,g,  hypogastric 
arteries;  //,  pulmonary  artery;  /,  right 
ventricle ;  /,  left  ventricle ;  k^  ductus  ar- 
teriosus;  /,  left  auricle;  m,  left  auriculo- 
ventricular  opening  ;  ;/,  foramen  ovale  ;  0, 
right  auricle  ;  /,  Eustachian  valve  ;  </,  right 
auriculoventricular  opening ;  ;-,  vena  cava 
ascendens ;  s,  liver;  t,  hepatic  vein;  «, 
branches  of  the  umbilical  vein  to  the  liver ; 
V,  umbilical  vein  ;  lu,  umbilical  cord  ;  x, 
bladder ;  i',  vena  cava  descendens ;  2, 
ductus  venosus  (Flint). 


conveys  a  mixed  blood,  still 
further  devitalized  from  the  infusion  of  the  venous  blood  from 
the  head,  neck,  and  upper  extremities,  to  the  trunk  and  lower 
extremities.  It  is  by  this  arrangement  that  a  greater  quantity 
of   arterial   blood    is  conveyed   to  the  brain,  which  develops  so 


90  PREGNANCY. 

rapidly  during  intra-uterine  life.  Following  the  blood-current 
down  the  aorta  to  the  iliac  arteries,  and  thence  to  their  internal 
branches,  two  arteries,  one  from  each  branch,  ascend  to  the 
umbilicus  whence  they  pass  out  of  the  body  to  form  the 
two  arteries  of  the  umbilical  cord.  Within  the  body  they 
are  known  as  the  hypogastric  arteries.  The  two  arteries 
of  the  cord  carry  to  the  placenta  vitiated  blood,  which,  in 
the  terminal  placental  villi,  discharges  into  the  maternal  blood 
the  effete  products  of  the  life-processes  in  the  fetus  and  re- 
ceives in  return  a  fresh  supply  of  oxygen  and  nutriment, 
and  probably  a  fair  share  of  the  soluble  salts  of  the  blood, 
as  well  as  any  other  substance,  medicinal  ^  or  otherwise,  that 
the  maternal  blood  may  contain  in  solution  or  possibly  even 
in  suspension. 

While  the  passage  of  matter  from  the  maternal  into  the 
fetal  blood  seems  to  occur  so  frequently,  it  would  appear  to  be 
more  difficult  for  substances,  aside  from  the  effete  products 
of  tissue  activity,  to  pass  from  fetus  to  mother.  There  is 
reason  to  believe,  however,  that  the  poison  of  syphilis  may 
take  this  course.  It  has  also  been  demonstrated  that  certain 
drugs,  as  strychnin,  may  pass  from  fetus  to  mother.  ^  The 
ease  with  which  medicinal  substances  pass  from  mother  to  fetus 
has  caused  anxiety  lest  in  the  administration  of  powerful  drugs 
to  the  mother  the  fetus  might  be  injuriously  affected.^  It  is 
possible,  of  course,  to  harm  the  fetus  by  administering  poisonous 
substances  to  the  mother,  but  it  is  extremely  unlikely  that  the 
fetus  will  be  much  affected  unless  the  dose  to  the  mother  much 
exceeds  the  usual  therapeutic  limit.  But,  like  the  adult,  the 
fetus  may  become  accustomed  to  a  drug,  and  be  able  finally  to 
endure  large  quantities  of  it  in  the  maternal  blood.  ^ 

The  temperature  of  the  fetus  in  utero  is  slightly  higher 
than  that  of  its  mother.  Priestley,  ^  in  experiments  on  rabbits 
and    cats,    found    the    temperature    of  the    fetus    about    i°    F. 

^  Chloroform,  carbonic  oxid  gas,  salicylate  of  sodium,  benzoate  of  sodium, 
atropin,  strychnin,  morphin,  quinin,  corrosive  sublirnate,  iodid  of  potassium,  ether, 
urea,  the  bile-salts,  soluble  salts  of  lead,  tobacco,  sulphindigolate  of  soda,  the  germs 
of  many  diseases,  have  all  been  known  to  pass  from  mother  to  fetus. 

2  Schroeder,  "  Geburtshiilfe,"  8th  ed.,  p.  63. 

*  Parvin's  "  Obstetrics,"  148. 

*  I  was  obliged  on  one  occasion  to  administer  very  large  doses  of  morphin 
daily  for  a  period  of  some  weeks  to  a  patient  who  was  suffering  from  general  septi- 
cemia in  the  seventh  month  of  pregnancy.  The  fetus  continued  to  move  actively  in 
utero,  and  I  could  detect  no  change  in  the  fetal  heart-sounds.  The  woman  finally 
gave  birth  to  a  living  infant. 

*  "  Lumleian  Lectures  on  the  Pathology  of  Intrauterine  Death,"  rep.  for 
"Brit.  Med.  Jour.,"  1887,  p.  16. 


THE  MATURE  FETUS.  9 1 

higher  than  that  of  its  mother.  Taking  the  temperature  /;/  ano 
of  a  fetus  coming  down  during  labor  by  the  breech,  and  com- 
paring it  with  the  temperature  of  the  vagina,^  or  taking  the 
temperature  of  infants  immediately  after  birth, ^  the  fetus  is  found 
warmer  than  the  mother  by  o.  5  °  C. 

Of  all  the  organs  in  the  fetal  body,  the  liver  is  the  most 
active.  Almost  all  the  oxygenated  blood  from  the  placenta 
goes  first  to  the  liver.  The  great  quantity  of  meconium  in 
the  fetal  intestines — a  substance  composed  mainly  of  bile- 
salts — attests  the  active  secretory  work  of  this  organ,  and  to 
it,  also,  may  be  attributed  the  source  of  the  large  quantity 
of  glycogen  ^  found  in  fetal  tissues,  especially  the  muscles, 
where  this  substance  probably  has  work  to  perform,  the  nature 
of  which  is  not  vet  understood. 


THE  MATURE  FETUS. 

There  is  no  single  sign  that  enables  one  to  declare  a  given 
fetus  to  be  fully  mature  ;  but  the  weight,  measurements,  and  stage 
of  development,  taken  together,  indicate  with  tolerable  accuracy 
the  length  of  time  that  the  fetus  has  remained  in  utero.  By  the 
two  hundred  and  eightieth  day  a  healthy  fetus  should  weigh 
about  3317  to  3459  gm.  (7^  to  7%  pounds),  according  to 
the  statistics  of  Lusk  and  Parvin  ;  but  in  Europe  the  weight  of 
the  mature  fetus  is  somewhat  less,  for  the  statistics  of  Scan- 
zoni,  Ingerslev,  Hecker,  Fesser,  and  Bailly,  including  a  very  large 
number  of  observations,  give  a  weight  of  less  than  3175  gm.  (7 
pounds).  Variations  in  weight  at  term  between  2728  and  4082  gm. 
(6  and  9  pounds)  *  are  by  no  means  rare,  and  the  range  of  possi- 
bility in  the  weight  of  a  mature  fetus  is  a  very  wide  one.  Thus 
Harris  ^  refers  to  an  infant  that  weighed  but  a  pound,  and  to 
another,  the  child  of  the  Nova  Scotia  giantess,  that  weighed 
13040.78   gm.    (28^  pounds)   at  term.      A   decided   departure, 

1  Wurster,  "Berlin,  klin.  Wochens.,"  1869,  No.  37,  and  "  Beitr.  z.  Tocother- 
mometrie,"  D.  i,  Zurich,  1870. 

2  See  Barensprung,    Miiller's    "  Archiv,"    1851  ;    Schafer.    D.    i,   Greifswald; 
Andral,  "  Gaz.  Hebd.,"  July,  1870 ;  Schroeder,  Virchow's  "Archiv,"  Bd.  xxxv,  h. 
261  ;  and  the  «  Lehrbuch,"  8th  ed.,  1894,  p.  65  ;  also,  Alexeeff,  "Archiv  f.  Gyn., 
Bd.  X,  S.  141. 

sMarchand,  "  Ueber  das  Glykogen  in  einigen  fotalcn  Geweben,"  Virchow's 
"Archiv,"  Bd.  c,  S.  42. 

4  An  infant  of  over  nine  pounds  is  not  common,  while  heavier  weights  are  pro- 
gressively rare  Out  of  1000  infants,  Dr.  Parvin  saw  but  one  that  weighed  II  pounds 
(Parvin's  "Obstetrics,"  p.  138).  Of  I156  infants  born  in  my  service  in  the  Mater- 
nity Hospital,  the  heaviest  weighed  12  pounds. 

5  Note  to  Playfair's  "  Midwifery." 


92  PREGNANCY. 

however,  from  the  normal  average  indicates,  on  the  one  hand, 
prematurity  or  a  weak  development ;  on  the  other,  the  prolonga- 
tion of  pregnancy,  race  peculiarities,  the  vigor  or  excessive  size 
of  the  parents,  especially  the  mother,  or  the  preoccurrence  of 
several  pregnancies.  Sex  also  influences  the  size  of  the  infant, 
males  being,  on  an  average,  larger  than  females.  The  length  of 
a  mature  fetus  is  51  to  53  cm.  (20  to  21  in.).  The  width  across 
the  shoulders  (binacromial  diameter)  is  about  12  cm.  (4.75  in.); 
the  dorsosternal  diameter  is  9  to  9.5  cm.  (3.5  to  3.75  in.);  the 
biniliac,  9.5  to  10  cm.  (3.75  to  4  in.).  The  length  of  the  foot  is 
about  8  cm.  (3.15  in.).i  The  dimensions  of  the  head  are  im- 
portant as  a  sign  of  the  development  of  the  fetus. 

The  following  dimensions  of  the  fetal  head  may  be  consid- 
ered characteristic  of  the  normally  developed  infant  directly 
after  its  expulsion  from  the  uterus  : 

Bitemporal  (B.  T.)  diameter, 8       cm.  (3.15  in.). 

Biparietal  (B.  P.)  diameter, .  914^  cm.  (3.64  in.). 

Occipitofrontal  (O.  F.)  diameter, 1 1 3^  cm.  (4.56  in.). 

Occipitomental  (O.  M.)  diameter, 13       cm.  (5.12  in.). 

Maximum  (M.  M.)  diameter, 13^  cm.  (5.32  in.). 

Suboccipitobregmatic  (S.  O.  B.)  diameter,    .  9^  cm.  (3.74  in.). 

Trachelobregmatic  (T.  B. )  diameter,     .    .    .  9^  to  10       cm.  (3.74  to  3.94  in.). 

Circumferences:  O.  F.,  341^  cm.  (13.5810.);  S.  O.  B.,  30  (11. 8)-^  O.  M.,  37  (14.5). 

These  dimensions  are  subject  to  modification.  Any  of  the 
causes  that  tend  to  increase  the  size  of  the  infant  as  a  whole  like- 
wise influence  the  size  of  the  head ;  but  even  with  a  normal 
body-weight  and  length  the  head  may  be  disproportionately 
large,  without  being  diseased. 

Another  valuable  sign  of  maturity  in  the  fetus  is  the  appear- 
ance and  extent  of  certain  centers  of  ossification. 2  In  the 
center  of  the  lower  epiphysis  of  the  femur  is  found  at  birth 
a  spot  of  ossification  measuring  five  millimeters  in  diameter, 
while  a  similar  but  smaller  spot  is  just  appearing  in  the  upper 
epiphysis  of  the  tibia.  The  center  of  ossification  in  the  astrag- 
alus is  found  without  difficulty,  for  it  first  appears  at  the 
seventh  month  of  intra-uterine  life.  The  center  of  ossification 
in  the  cuboid  bone  is  at  birth  beginning  to  make  its  appearance. 
The  ossified  spot  in  the  lower  epiphysis  of  the  humerus  only 
appears  some  months  after  birth. 

The  general  appearance  of  a  new-born  infant  is  of  value  as 
indicating  whether  or  not  the  fetus  had  reached  maturity  before 
its  expulsion  from  the   uterus.      A  healthy  infant  at  term  looks 

1  Negri  says  ("Ann.  di  Ostet.,"  May  to  June,  1885)  that  when  the  foot  measures 
eight  centimeters  the  fetus  is  well  developed  and  weighs  about  3500  gm. 

2  See  Rossie,  "Amer.  Jour,  of  Obstetrics,"  1886,  p.  18. 


THE  MATURE  FETUS. 


93 


stout  and  well-nourished.  The  face  is  plump  and  is  free  from 
lanugo  ;  miliaria  are  seen  about  the  tip  of  the  nose,  but  are 
not  nearly  so  evident  as  they  were  in  the  ninth  month  of 
intra-uterine  existence.  The  eyes  are  usually  opened,  the  limbs 
move  vigorously,  and  the  child  seizes  with  its  lips  the  nipple 
when  presented  to  it,  and  sucks  with  energy.  The  vernix 
caseosa  is  abundant  only  on  the  back  of  the  child  and  on  the 
flexor  surface  of  the  limbs.  The  nails  project  beyond  the  finger- 
tips ;  the  cartilage  of  the  ears  and  nose  feels  firm  ;  eyebrows  and 
eyelashes  are  well  developed  ;  the  hairs  of  the  scalp  are  about 
an  inch  long  ;  the  bones  of  the  head  are  hard  and  lie  close 
together.  The  breasts  in  both  sexes  are  large,  and  usually  a  thin 
fluid  can  be  squeezed  out  of  them.  In  boys  the  testicles  are" 
usually  to  be  felt  in  the  scrotum,  although  the  tunica  vaginalis 
is  not  yet  closed.  In  girls  the  labia  majora  are  usually  approxi- 
mated, although  occasionally  the  nymph^e  project  between  them. 
The  Determination  of  Sex. — In  all  countries  the  number  of 
male  children  born  exceeds  the  number  of  females,  the  average 
proportion  being  io6  to  lOO  ;  but,  as  more  boys  die  than  girls, 
by  the  time  puberty  is  reached  the  sexes  are  about  equal  in  num- 
ber. The  law  that  governs  the  production  of  sex  has  long  been 
a  subject  of  discussion  and  speculation.  The  Hippocratic  doc- 
trine that  the  right  ovary  produced  boys  and  the  left  girls  was 
accepted  for  centuries,  and  upon  this  belief  was  founded  the 
precept  that  women  who  desired  male  offspring  should  lie  during 
coitus  upon  the  right  side,  while  those  who  desired  daughters 
must  lie  upon  the  left  side.  By  experiments  upon  animals,  by 
the  observation  of  women  in  whom  one  ovary  was  destroyed  by 
disease  or  removed  by  an  operation,  and  by  a  more  complete 
knowledge  of  the  mechanism  of  impregnation,  the  long-accepted 
teaching  of  Hippocrates  was  disproved,  although  not  until  com- 
paratively recent  times.  At  present  it  is  undecided  whether 
the  question  of  sex  is  determined  before  impregnation  occurs, — 
that  is,  whether  certain  spermatic  particles  or  ovules  are  predes- 
tined to  produce  males,  while  others  produce  females  ;  whether 
the  sex  is  impressed  upon  the  ovule  at  the  moment  of  conception, 
or  whether  the  embryo  is  possessed  of  the  elements  of  both 
sexes  until  one  or  the  other  acquires  a  preponderating  influence 
owing  to  causes  which  may  be  operative  during  the  early  part 
of  pregnancy.  The  first  theory  receives  its  chief  support  from 
the  fact  that  unioval  twins  are  invariably  of  the  same  sex,  which 
looks  as  though  the  ovule  was  predestined  in  the  ovary  to  the 
formation  of  one  or  the  other  sex.  The  last  theory  is  based 
upon  the  study  of  plants  and  lower  animals,  in  which  the  sex  is 
only  determined  at  some  time  after  conception   by  the  influence 


94 


PREGNANCY. 


of  nourishment ;  overfeeding  being  found  to  produce  females, 
underfeeding  to  produce  males.  It  is  possible  in  the  case  of 
certain  animals  to  alter  the  sex,  or  at  least  to  produce  her- 
maphrodites, even  after  the  sexual  organs  have  begun  to  be  dif- 
ferentiated. ^  This  theory  is  further  supported  by  the  fact 
that  in  the  human  embryo  the  elements  of  both  sexes  are  always 
present  apparently  in  equal  force  during  the  early  part  of  em- 
bryonal life.  The  belief  that  the  sex  of  a  human  embryo  is 
impressed  upon  it  at  the  moment  of  conception  rests  upon  the 
fact  that  in  certain  conditions  of  nutrition  or  sexual  vigor  in  one 
or  the  other  parent  one  sex  preponderates,  while  under  opposite 
conditions  the  other  sex  is  most  frequently  produced. ^ 

The  most  diverse  conditions  have  been  held  accountable 
for  departures  from  the  normal  numerical  relation  of  the  sexes 
at  birth.  Illegitimacy, ^  age  of  parents,'*  conception  at  certain 
periods  after  menstruation,^  deformities  in  the  female  pelvis, ^ 
the  nutrition  or  sexual  vigor  of  the  parents,'^  the  tendency  of 
each  sex  to  produce  the  opposite  or  the  reverse,^  the  tend- 
ency to  produce  that  sex  which  is  most  needed  to  perpetuate 
the  species,^  the  season   of  the  year, ^^  climate   and  altitude, ^^ 

1  In  the  case  of  the  larvae  of  bees  from  impregnated  eggs,  when  the  female  gen- 
ital organs  have  begun  to  appear,  if  the  nourishment  is  very  insufficient,  instead  of 
becoming  female  workers  these  animals  will  actually  develop  into  true  hermaphro- 
dites, with  the  organs  of  both  sexes  (Fiirst). 

2  Thury  ("Zeitsch.  f.  w.  Zoologie,"  1863,  Bd.  xiii,  S.  541)  found  in  29  experi- 
ments upon  cattle  that  in  every  case,  if  connection  occurred  at  the  beginning  of  heat, 
females  were  produced  ;  if  at  the  end,  males. 

3  Fiirst  ("  Archiv  f.  Gyn.,"  Bd.  xxviii,  S.  19)  says  that  in  illegitimate  births  the 
males  fall  below  the  average  (based  upon  807,332  cases).  This  coincides  with  my 
experience  in  the  Maternity  Hospital  in  more  than   looo  cases  of  illegitimate  births. 

4  See  Hofacker,  "  Ueber  die  Eigensch.  welche  sich  von  den  Eltern  auf  die 
Nachk.  vererben,"  1828 ;  Sadler,  "Law  of  Population,"  London,  1830  ;  Hecker, 
"Archiv  f.  Gyn.,"  Bd.  vii,  S.  448;  Bidder,  "Zeitsch.  f.  Geburtsh.,"  Bd.  ii,  S. 
358  ;  .Ahlfeld,  "Archiv  f.  Gyn.,"  Bd,  ix,  S.  448;  Wall,  "  The  Causation  of  Sex," 
London  "  Lancet,"  1887,  i,  pp.  261,  307. 

5  Thury,  loc.  cit.  ;  Coste,  "  Comptes  Rendus,"  1865  ;  Schroeder,  "  Lehrbuch," 
8te  Aufl.,  1884,  S.  33;  Fiirst,  "  Knaben  Ueberschuss  nach  Conception  zur  Zeit  der 
postmenstruellen  Anamie,"  "Archiv  f.  Gyn.,"  Bd.  xxviii,  S.  18. 

•^  Olshausen,  "  Klinische  Beitrage,"  Halle,  1884;  Linden,  "Hat  das  enge 
Becken  einen  Einfluss  auf  die  Entstehung  des  Geschlechts  ? "  Dis.  Inaug.,  Mar- 
burg, 1884;   R.  Dohrn,  "Zeitsch.  f.  Geburtsh.  u.  Gyn.,"  Bd.  xiv,  S.  80. 

''  See  Fiirst,  loc.  cit.,  and  Schroeder,  op.  cit.,  S.  33.  Also  Schenk  (Determination 
of  Sex,  authorized  translation,  Chicago,  1898),  who  believes  that  imperfect  metabolism 
and  glycosuria  in  the  mother  predispose  to  female  offspring,  while  a  strong  nitrogenous 
diet  and  absence  of  sugar  in  the  urine  prepare  a  woman  to  bear  male  offspring. 

*  See  Fiirst,  loc.  cit. 

9  Diising,  "  Die  Regulirung  des  Geschlechtsverhaltnisses  bei  der  Vermehrung 
der  Menschen,  Thiere,  u.  Pflanzen,"  Jena,  1884. 

1"  According  to  Diising  [loc.  cit.),  women  impregnated  in  summer  give  birth 
to  fewer  boys  than  those  impregnated  in  winter  (conclusions  based  on  more  than 
10,500,000  births). 

11  Floss  found,  in  Saxony,  that  up  to  2000  feet,  the  greater  the  altitude,  the  larger 
was  the  number  of  male  births  (at  2000  feet,  107.8  to  100). 


THE   MATURE   FETUS.  95 

diet/  and  the  degeneration  of  a  race,  as  during  the  decadence  of 
imperial  Rome,-' — have  all  been  advanced  as  reasons  for  ap- 
parent excess  in  the  number  of  male  or  female  births.  These 
theories,  however,  have  been  found  false  or  inadequate  upon 
further  investigation.  An  explanation  of  the  determination  of 
sex  is  not  yet  obtained,  and  the  production  of  the  sexes  at  will  is 
still  impossible. 

Multiple  Fetation. — It  is  the  rule  that  but  one  fetus  at  a 
time  is  developed  within  the  uterus  of  a  human  female.  Once  in 
about  120  pregnancies,^  however,  two  fetuses  are  developed 
simultaneously  in  the  same  uterus,  so  that  twins  are  not  of  un- 
common occurrence.  Triplets  are  found  once  out  of  7900, 
quadruplets  once  out  of  371,126  births.  Quintuplets  are  ex- 
tremely rare.  There  is  one  case  of  sextuplets  on  record.* 
Multiple  fetation  maybe  the  result:  (i)  Of  the  impregnation 
of  a  single  ovum  that  contains  two  or  more  germinal  vesicles, 
or  in  which  the  formative  material  of  the  area  germinativa 
divides  f  (2)  of  the  impregnation  of  two  or  more  ova  which 
were  contained  either  in  one  Graafian  follicle  or  in  separate 
follicles,  the  latter  being  situated  either  in  one  or  both  ovaries; 
(3)  of  the  penetration  of  the  ovum  by  more  than  one  spermato- 
zoon ;  (4)  of  the  impregnation  of  ovules  escaping  at  different 
times  from  different  Graafian  follicles  (superfetation).*  There 
may  be  a  hereditary  disposition  to  multiple  fetation.  Boer 
reported,  in  1808,  an  extraordinary  example:'  A  woman 
aged  forty  had  in  1 1  pregnancies  during  twenty  years  given 
birth  to  32  children,  to  wit:  quadruplets  twice,  triplets  six 
times,  twins  thrice.  The  woman  herself  was  one  of  quadru- 
plets and  her  mother  had  had  38  children.  Her  husband  was 
one  of  twins,  and  there  was  a  history  of  other  plural  births  in 
his  family. 

If  the  multiple  fetation  is  the  result  of  the  impregnation 
of  a  single  ovum,  there  is  but  one  chorion  and  one  dccidua 
reflexa,    although   each   fetus    is   inclosed    in    its   own    amnion.'^ 

1  J.  C.  Webster,  "  Some  Fundamental  Problems  in  Obstetrics  and  Gynecology," 
"  Amer.  Med.,"  Dec.  10,  1904. 

2  Darwin's  Collected  Works. 

^  According  to  statistics  collected  by  Veit,  based  on  more  than  13,000,000  births, 
twins  occur  once  in  89  pregnancies ;  in  New  York  and  Philadelphia  the  proportion 
is  about  I  to  120. 

4  Vassali,  "  Gaz.  Med.  Ttal.  Lombardia,"  Milano,  1888,  No.  38. 

5  Ahlfeld,  "Archiv  f.  Gyn.,"  Bd.  ix,  S.  196. 

^  Slavjansky  has  observed  a  recent  ovulation  in  a  woman  tliree  months  pregnant, 
but  with  extra-uterine  pregnancy.  ''  "  Wien.  med.  Wochens.,"  No.  3,  1897. 

8  Occasionally  two  fetuses  are  found  in  a  .^inijk'  amniotic  cavity,  which  is  to  be 
explained  (l)  by  the  atrophy  and  absorjition  of  the  toiiiiguous  amniotic  walls  ;  (2)  by 
rupture  of  the  amnion  in  the  latter  montlis  from  llic  vigorous  luovcnKiits  of  the  fetus; 
or  (3)  by  the  development  of  but  a  single  amnion  from  the  very  beginning  (Mysch- 
kin,  Virchow's  '*Archiv,"  Bd.  cviii,  S.  133,  146). 


96 


PREGNANCY. 


In  these  cases  the  sex  of  the  fetuses  is  the  same.  The 
placentae  are  usually  found  intimately  united  when  expelled  at 
term,  presenting  extensive  arterial  and  venous  anastomoses — 
a  condition  that  may  give  rise  to  the  deformity  of  one  of  the 

twins,  known  as  acardia. 
But  in  the  early  stages  of 
development  each  placenta, 
even  in  unioval  twins,  is 
separate.  When  the  em- 
bryos are  derived  each  from 
a  separate  ovum,  there 
should  be  separate  deciduae 
reflexae,  chorions,  and  pla- 
centae. Occasionally,  how- 
ever, when  the  ova  are  im- 
planted close  together,  the 
placentae  may  be  joined, 
there  may  be  but  one 
decidua  reflexa,  and  it 
may  be  difficult  to  detect 
the  double  layer  of  chorion 
that  should  separate  the 
two  ova. 

Although  twins  are  not 
infrequently  born,  the  con- 
dition should  be  regarded  as 
pathological.  From  statis- 
tics collected  by  Schatz,  ^ 
it  appears  that  in  twins 
from  different  ova  one  is 
born  dead  in  every  twenty-three  cases,  while  from  the  same  ovum 
the  death-rate  is  one  in  six.  One  fetus  may  outstrip  its  fellow  in 
growth,  and  divert  the  greater  part  of  the  nourishment  from  the 
mother  to  itself,  thus  growing  rapidly  and  encroaching  so  much 
upon  the  room  that  should  belong  to  the  weaker  fetus  that  the 
latter  is  killed  and  finally  pressed  flat  against  the  uterine  wall 
(foetus  papyraceus).  Hydramnios  is  also  very  common  in  twin 
pregnancies,  and  occasionally  one  fetus  is  converted  into  an 
acardiac  monster.  If  the  fetuses  of  a  twin  pregnancy  escape 
the  dangers  of  intra-uterine  life,  there  are  many  complications 
awaiting  them  in  labor.  Should  one  fetus  die  during  pregnancv, 
it  is  usually  retained  until  term,  when  the  living  and  the  dead  child 
are  cast  off  together,  widely  different  in  appearance  and  develop- 


Fig.  71. — Fetus  papyraceus 
(author's  specimen). 


1  "  Archiv  f.  Gyn.,"  Bd.  xxix,  S.  438. 


THE   MATURE   FETUS. 


97 


ment ;  ^   or  else  one  ovum  may  be  aborted  at  an  early  period  of 
pregnancy,  while  the  other  goes  on  developing  until  term. - 

Even  though  both  children  have  been  retained  m  utcro  an 
equal  length  of  time,  there  is  usually  a  marked  difference  in 
their  length  and  weight,  especially  if  they  have  resided  in  one 
ovum.  3  In  cases  of  uterus  duplex,  fetuses  of  different  ages 
have  been  found  in  the  two  divisions  of  the  uterus.  Fordyce 
Barker  reports  a  case  of  delivery  of  two  mature  children  from  a 
woman  with  a  double  uterus,  one  male,  the  other  female,  at  an 
interval  of  two  months.'*  Upon  such  cases,  and  also  upon  the 
fact  that  of  twins  in  negresses  rarely  one  is  light  and  the  other 
dark,  showing  probably  different  paternity,  has  been  based  the 
theory  of  superfetation  ;  but  as  there  is  no  clear  proof,  as  yet, 
of  the  occurrence  of  ovulation  during  pregnancy,  the  possibility 
of  the  impregnation  of  ovules  which  escaped  from  their  Graafian 
follicles  at  rather  wide  intervals  of  time,  say  weeks  or  months, 
is  doubtful.^ 

1  Scbultze,  "  Volkm.  Samml.  klin.  Vortrage,"  No.  34. 

2  Sirois,  "L'Union  medicale  du  Canada,"  July,  1887;  and  Warren,  "Am 
Jour.  Obstetrics,"  1887. 

3  Schatz,  loc.  cit. 

4  See  Lusk,  op.  cit.,  p.  233,  ed.  1886. 

5  For  some  interesting  observations  which  would  seem  to  indicate  the  possibility, 
at  least,  of  ovulation  during  pregnancy,  see  "  Ovulation  During  Pregnancy,"  Chris- 
topher, "  Am.  Jour.  Obstetrics,"  1886,  p.  457, 

7 


98 


PREGNANCY, 


CHAPTER    IV. 

The  Developmentt  the  Anomalies,  and  the  Diseases  of  the  Fetal 

Appendages:   the  Membranes,  the  Placenta, 

and  the  Umbilical  Cord* 

The  study  of  the  development,  anomalies,  and  diseases  of 
the  fetal  appendages  is  necessary  to  a  clear  understanding  of 
fetal  pathology.  First  will  be  considered  the  development  and 
diseases  of  the  fetal  appendages  springing  directly  from  the 
embryo — namely,  the  amnion,  the  chorion,  the  allantois,  and 
the  placenta ;  lastly,  the  deciduae,  the  maternal  envelope  of  the 
fetus. 

THE  AMNION. 

After  segmentation  has  occurred,  and  after  the  interior  of 
the  ovum  has  become  reduced  to  a  granular  mass,  around  which 
is  a  membrane  composed  of  a  single  layer  of  cells,  at  a  certain 
point — the  embryonal  area — in  this  membrane  there  appears  a 
thickening,  by  a  heaping  up  of  the  cells.  Finally  this  mass  of 
cells  resolves  itself  into  two  layers  (ecto-  and  entoderm),  and 
between  these  two   appears  another  layer  of  cells  (mesoderm). 

The  outer  layer,  the  ectoderm,  sends  a  prolongation  around 
the  whole  interior  surface  of  the  ovum,  and  this  layer  receives  a 


Fig.  72. — e.  Embryo  ;  ec,  cephalic 
extremity ;  eg,  caudal  extremity ;  ca, 
ca,  amniotic  hood  ;  //,  pp,  pleuroperi- 
toneal  cavity  ;  y,  umbilical  vesicle. 


Fig-  73- — e,  Embryo  ;  a,  amnion  ; 
oa,  amniotic  umbilicus ;  cac,  amnio- 
chorional  cavity  ;  //,  pp,  pleuroperito- 
neal  cavity ;  ch,  chorion  ;  mv,  vitel- 
line membrane  ;   vo,  umbilical  vesicle. 


THE  AMNION. 


99 


reinforcement  from  the  middle  layer  of  cells,  or  the  mesoderm. 
It  was  formerly  believed  that,  as  the  embryo  assumes  a  definite 
shape,  the  lateral  walls  folding  in  toward  one  another,  and  the 
caudal  extremity  approaching  the  cephalic  end  of  the  embrvo, 
the  outer  layer  of  cells,  forming  a  membrane  continuous  with  the 
outer  covering  of  the  embryo,  instead  of  being  simply  carried  for- 

Amniotic  cavity 


Amniotic  cavity 


Amniotic  cavity 


Periembryonal 
mesodermal  cleft 


Periembryonal  mesodermal  cleft 


Amniotic  cavity 


Periembryonal 
mesodermal 
cleft 


Periembryonal 
mesodermal 
cleft 


Yolk-sac 
Fig.  74. — Scheme  of  development  of  the  amnion  (Pfannenstiel). 


ward  to  meet  in  the  median  line  in  front,  sends  reduplications 
backward  over  the  dorsal  aspect  of  the  embryo,  which  shortly 
meet  and  join  one  another;  that  there  are  consequently  two  cavi- 
ties formed, — one  within  the  membrane  doubled  back  upon  itself; 
the  other  between  the  inner  (the  true  amnion)  of  the  two  layers 
of   membrane   and   the   outer    covering   of    the   embryo.      The 


lOO  PREGNANCY. 

latter  is  the  true  amniotic  cavity,  which  is  gradually  distended 
by  the  accumulation  of  fluid  until  the  membrane  containing  it 
is  pushed  out  on  all  sides,  uniting  in  front  around  the  umbilical 
cord,  and  coming  in  contact  throughout  the  whole  extent  of 
the  ovum  with  the  outer  membrane  (true  chorion),  to  which  it 
becomes  loosely  united  by  a  gelatinous  substance, — the  tunica 
media  of  Bischoff. 

This  theory  is  not  tenable  in  view  of  the  observations  of  Peters 
and  Graf  Spee,  which  demonstrate  that  the  amniotic  cavity  is 
closed  at  a  very  early  date.  There  must,  therefore,  be  a  separation 
in  the  cells  of  the  ectoblast  constituting  a  cavity,  which  as  it  dis- 
tends with  fluid  presses  the  embryonal  area  toward  the  umbilical 
vesicle  or  yolk-sac,  and  folds  the  amnion  around  the  embryo  till 
the  latter  is  completely  enclosed. 

The  Fully=developed  Amnion.  —  The  amnion  forms  the 
innermost  of  the  membranes  that  surround  the  fetus  at  term. 
It  is  continuous  with  the  fetal  epidermis  at  the  umbilicus,  forms 
a  complete  sheath  for  the  umbilical  cord,  and  covers  the 
fetal  surface  of  the  placenta.  In  its  structure  it  consists 
of  a  single  layer  of  flat  endothelial  cells  turned  toward  the 
cavity  of  the  amnion,  and  externally  of  ac  layer  of  young 
connective  tissue,  in  which  may  be  seen  long  spindle-  or  star- 
shaped  cells  with  long  nuclei  imbedded  in  a  fibrous  substance. 
The  regular  disposition  of  the  inner  layer  of  endothehal  cells, 
however,  is  disturbed  at  certain  points  of  the  amnion  lying  over 
the  placenta,  where  numbers  of  cells  are  heaped  together,  forming 
a  httle  villus-like  projection.  There  are,  normally,  no  blood- 
vessels in  the  amnion, — at  least,  in  its  later  stages  of  develop- 
ment; their  possible  occurrence  in  hydramnios  is  referred  to 
later. 

The  Liquor  Amnii. — It  is  the  physiological  function  of  the 
amniotic  membrane  to  furnish  a  fluid  medium  (the  liquor  amnii), 
which  distends  the  uterine  walls  and  allows  the  fetus  some  free- 
dom of  movement,  and,  by  its  density,  approaching  the  specific 
gravity  of  the  fetus,  robs  these  movements  of  much  muscular 
effort.  It  acts  as  an  additional  protection  to  the  fetus  from  ex- 
ternal violence,  pressure,  and  changes  of  temperature  ;  it  receives 
the  urine  secreted  in  the  latter  part  of  fetal  life  ;  and,  perhaps, 
plays  a  part  in  the  nutrition  of  the  fetus,  or  at  least  in  supplying 
the  fetal  tissues  with  the  excess  of  water  which  the\'  possess 
during  intra-uterine  life.^  That  the  fetus  actually  swallows 
considerable   quantities   of  liquor  amnii  admits  of  no  doubt,  for 

1  Preyer,  "Physiologic  des  Embrv'os." 


THE  AMNION.  lOI 

lanugo  and  epidermis-scales  have  been  found  in  the  meconium,  ^ 
and  also  particles  of  colored  matter  which  had  entered  the 
amniotic  fluid  from  the  maternal  structures  (Zuntz).  It  is  not 
likely  that  the  liquor  amnii  plays  an  important  part  in  the 
nutrition  of  the  fetus,  as  claimed  by  von  Ott  and  others  ;  for  if 
it  did,  the  birth  of  well-nourished  children  with  a  breach  of  con- 
tinuity in  the  upper  part  of  the  alimentary  tract  from  the  mouth 
to  the  small  intestine  would  be  inexplicable. 

The  Composition  of  the  Liquor  Amnii The    amniotic    fluid   is 

usually  almost  clear ;  occasionally,  however,  opaque,  whitish, 
greenish,  or  a  dark  brown  from  the  presence  of  meconium,  or  of 
a  reddish  color  when  the  fetus  is  macerated.  The  specific  gravity 
varies  from  1002  to  1028  (Schroeder),  being  usually  about  1007 
to  10 1 1.  Its  reaction  is  slightly  alkaline.  It  contains  salts, 
urea,  carbonate  of  amrtionia,  kreatinin,  albiimin,  lanugo,  seba- 
ceoum matter,  epidermis-sfcales  from  the  fetal  skin,  and  epithe- 
lium from  the  bladder  and  kidneys.  The  quantity  of  the  liquor 
amnii  differs  at  different  periods  of  pregnancy  ;  in  the  early  stages 
it  develops  with  great  rapidity,  and  at  the  middle  of  pregnancy 
has  reached  its  maximum  of  about  i  to  1.5  kilograms  (2.2  to 
3.3  pounds)  (Landois).  From  this  time  it  diminishes  in  amount, 
until  at  the  end  of  pregnancy  its  average  quantity  is  680  gm. 
(1.5  pounds).  2 

The  Origin  of  the  Liquor  Amnii.— The  liquor  amnii  is  derived 
from  both  mother  and  fetus.  The  maternal  origin  ^  of  the  amniotic 
fluid  has  been  demonstrated  by  Zuntz,  who  injected  sodium  sul- 
phindigolate  into  the  veins  of  pregnant  rabbits,  and  found  a  blue 
coloration  of  the  amniotic  fluid,  although  there  was  no  coloring 
matter  in  the  kidneys  of  the  fetus.  In  cases  in  which  the  em- 
bryo is  destroyed  very  early,  moreover,  an  amount  of  amniotic 
fluid  may  be  found  corresponding  not  to  the  age  of  the  em- 
br}'o,  but  to  that  of  the  ovum.  And  it  is  not  unusual  to  find 
hydramnios  associated  with  some  other  serous  effusion  in  the 
mother.* 

1  Zweifel,  "  Untersuchungen  iiber  das  Meconium,'"  ".Vichiv  f.  Gyn.,"  I'.d.  vii.  474. 

2  Fehling,  "Archiv  f.  Gyn.,  "Bd.  xiv,  S.  221. 

3  Ahlfeld  ("Ueber  die  Genese  des  Fruchtwassers,"  ".Vrcliiv  f.  Gyn.,"  l'.d.  xiii. 
pp.  160-241  )  gives  an  ingenious  explanation  of  the  manner  in  whicii  llie  maternal 
structures  take  part  in  the  formation  of  the  liquor  amnii  :  As  the  uterus  develops  by 
an  eccentric  hypertrophy,  the  pressure  within  the  uterine  cavity  becomes  less  than 
that  of  the  abdominal  cavity,  and  consequently  there  is  a  disposition  for  the  scrum  of 
the  maternal  blood  to  exude  into  the  amniotic  cavity.  As  Phillips  ("  Kdin.  Med. 
Jour.,"  March,  1887,  p.  811)  remarks,  however,  the  case  of  hydramnios  in  extra- 
uterine pregnancy  ("Archiv  f.  Gyn.,"  P.d.  xxii,  \>.  57),  reported  by  Teuffel,  would 
seem  to  invalidate  this  theory. 

■tPfluger's  "Archiv,"  Bd.  xvi,  S.  548  ;  and  Wiener,  "Archiv  f.  Gyn  ,"  Bd.  xvii, 
S.  24. 


102  PREGNANCY. 

The  fetus  also  contributes  to  the  formation  of  liquor  amnii. 
The  excretion  of  urine  during  the  latter  part  of  fetal  life  reaches 
a  considerable  amount.  More  than  three  pints  of  urine  have 
been  found  retained  in  the  fetal  bladder.  ^ 

Gusserow  ^  injected  benzoic  acid  into  the  mother,  and  re- 
covered it  as  hippuric  acid  in  the  liquor  amnii,— proof  that  it 
had  passed  through  the  kidneys  of  the  fetus.  Wiener  found 
sodium  sulphindigolate  in  the  fetal  kidneys  and  bladder  after  it 
had  been  injected  into  the  maternal  tissues.  The  constant 
presence  of  urea  ^  in  the  amniotic  fluid  after  the  sixth  week 
is  additional  proof  of  the  renal  activity  of  the  fetus.  It  is 
probable  also  that  the  vasa  propria,  discovered  by  Jungbluth,* 
lying  close  under  the  amnion  in  the  early  life  of  the  embryo, 
have  something  to  do  with  the  production  of  the  amniotic  fluid. 
Prochownik  ^  claimed-  that  the  skin  of  the  fetus  secretes  amniotic 
fluid  during  the  early  months  of  gestation.  There  have  been 
cases  of  hydramnios  associated  with  morbid  conditions  of  the 
skin,  notably  one  instance  observed  by  Budin,^  in  which  the  skin 
of  the  fetus  was  the  seat  of  extensive  nevi.  Thus  it  appears  that 
the  amniotic  fluid  is  derived  from  a  fetal  as  well  as  a  maternal 
source,  but  the  relative  importance  of  the  fetal  and  maternal 
supply  of  liquor  amnii  at  different  periods  of  pregnancy  is  still 
undetermined. 

Abnormalities  of  the  Amnion. — There  is  a  striking  simi- 
larity between  the  pathology  of  the  amnion  and  that  of  other 
serous  membranes.  There  is  the  same  liability  to  changes  of 
secretion,  to  inflammation  with  a  plastic  exudate,  and  to  the  for- 
mation of  bands  of  adhesion.  The  function  of  the  amnion,  how- 
ever, and  its  close  relation  to  the  embryo  and  fetus,  give  rise,  in 
case  of  disease,  to  symptoms  and  results  peculiar  to  itself. 

Abnormalities  of  Secretion  :  Oligohydramnios, — Occasionally 
the  quantity  of  fluid  is  so  deficient  as  to  seriously  interfere 
with  the  growth  of  the  fetus  and  to  determine  its  premature 
expulsion.^  Schatz^  reports  a  case  in  which  there  were  ulcers 
on  the  inner  surface  of  the  knees  and  malleoli  of  a  fetus  from 
constant  friction  due  to  a  deficient  quantity  of  liquor  amnii,  and 
many  curious  deformities  of  the  fetus  may  be  traced  to  the  same 

^  Lefour,  "Archives  de  Tocol.,"  June  30,  1887. 

2  "Archiv  f.  Gyn.,"  Bd.  xiii,  S.  56. 

^  Prochownik,  "Archiv  f.  Gyn.,"  Bd.  xi,  S.  304-561. 

*  "  Beitr.  zur  Lehre  v.  Fruchtwasser,"  Inaug.  Dissert.,  Bonn,  1869;  Vir- 
chow's  "Archiv,"  Bd.  xlviii,  S.  523  ;    "Archiv  f.  Gyn.,"  Bd.  iv,  S.  534. 

*  Loc.   cit.  6  Tarnier  et  Budin,  loc.  at.,  p.  279. 
'  "London  Lancet,"  1886,  ii,  p.  383. 

*  "Archiv  f.  Gyn.,"  Bd.  xix,  S.  329. 


THE  AMNION. 


103 


cause.  1  This  condition  is  called  oligohydramnios.  More  fre- 
quently the  quantity  of  the  liquor  amnii  becomes  abnormally 
increased — a  condition  known  as  polyhydramnion,  hydroamnion, 
dropsy  of  the  amnion,  or,  more  commonly,  hydramnios. 

Hydramnios. — It  has  been  already  stated  that  the  normal 
quantity  of  liquor  amnii  at  the  end  of  pregnancy  is  from  one 
to  two  pints.  Should  this  quantity  be  much  exceeded,  the 
condition  of  hydramnios  exists.  A  slight  excess  is  frequent, 
but  usually  passes  unnoticed,  while  an  accumulation  of  fluid 
amounting  to  two  quarts  or  more  is  not  common.  It  is  difficult, 
therefore,  to  express  the  relative  frequency  of  hydramnios.  Char- 
pentier  states  that  it  occurs  in  i  in  100  or  i  in  150  pregnancies, 
— an  estimate  too  low  for  the  minor  grades  of  the  affection,  but 
too  high  for  cases  in  which  the  accumulation  of  fluid  is  large 
enough  to  give  rise  to  well-marked  symptoms.  In  the  majority 
of  cases  the  fluid  collects  gradually,  but  steadily,  until  at  the  end 
of  the  pregnancy  it  may  reach  the  enormous  quantity  of  six 
gallons  or  more.^  Occasionally  the  fluid  accumulates  very 
rapidly,  giving  rise,  from  the  sudden  distention  of  the  uterus, 
to  symptoms  of  a  grave  character.  The  rapid  accumulation  is 
known  as  acute  hydramnios. 

TJie  Etiology  of  Hydranmios. — It  may  be  due  to  {A)  an  over- 
secretion  of  liquor  amnii  or  to  (i?)  a  deficient  absorption  of  the 
liquor  amnii. 

A.  The  excessive  collection  of  fluid  may  be  derived  from  (I) 
a  maternal  source,  (II)  a  fetal  source,  or  (III)  both  fetus  and 
mother  may  contribute  to  its  production. 

I.  The  Maternal  Origin. — It  is  probable  that  the  serum 
of  the  maternal  blood  occasionally  exudes  in  abnormall)'  large 
quantities  into  the  amniotic  cavity.  In  cases  of  hx'dramnios 
associated  with  serous  effusions  elsewhere  in  the  mother's  body 
the  excess  of  liquor  amnii  is  probably  derived  from  a  maternal 
source.  Fehlino-  ^  asserts  that  "  the  thinner  the  maternal  blood, 
the  greater  is  the  quantity  of  liquor  amnii."  A  lymphagogue 
has  been  found  in  the  liquor  amnii  of  hydramnios,  which  is  not 
present  in  the  normal  liquid.  It  has  been  claimed,  therefore, 
that  this  substance  stimulates  a  serous  exudate  from  the  maternal 
blood.4 

II.  The  Hydramnios  May  Originate  Entirely  front  Fetal 
Structures. — This  supposition  explains  by  far  the  larger  number 

^  See  "Tarnier  et  Budin,"  p.  294. 

2  Wilson,  "Am.  Jour.  Obstetrics,"  Jan.,  1887,  p.  22. 

3  "  Archiv  f.  Gyn.,"  Bd.  xxviii,  .S.  454. 

*  E.  Opitz,  "Centralbl.  f.  Gyn.,"  No.  21,  1898. 


I04  PREGXA\'CY. 

of  cases  that  admit  of  an  explanation  at  all,  for  hydramnios 
often  occurs  (forty-four  per  cent,  of  all  cases  ( Bar ))  without 
a  demonstrable  cause  in  either  mother  or  fetus.  The  production 
of  hydramnios,  traced  to  the  fetus,  may  be  due  :  {a)  To  abnormal 
pressure  in  the  blood-vessels  of  the  cord,  or  of  those  directly 
under  the  amnion,  where  it  covers  the  placenta  (persistence  of  the 
vasa  propria  of  Jungbluth);  {B)  to  an  excessive  urinar}-'  secretion  ; 
{c)  to  an  abnormall}'  profuse  excretion  from  the  fetal  skin. 

{ci)  The  vasa  propria  of  Jungbluth,  normally  present  in  the 
early  stage  of  embryonal  development,  have  been  found  at  term 
in  cases  of  hydramnios, ■•■  and  the  production  of  an  excessive 
quantity  of  liquor  amnii  has  been  attributed  to  their  persistence. 
It  is  more  probable,  however,  that  the  existence  of  these  vessels 
is  purely  secondary',  and  that,  although  the  serum  of  the  fetal 
blood  does  exude  from  them  into  the  amniotic  cavity,  their 
presence  is  due  to  an  increased  blood-pressure  in  the  umbilical 
vein.^  Increased  internal  pressure  within  the  umbilical  vein 
causes  a  transudation  through  the  amnion,  as  has  been  proved 
by  Salinger,^  who  found  that  the  amount  of  fluid  which 
w^ould  transude  depended  upon  the  strength  of  the  pres- 
sure and  the  size  of  the  cord.  Any  condition  of  the  fetus, 
therefore,  which  raises  the  blood-pressure  in  the  umbilical  vein, 
thus  increasing  the  blood-pressure  in  the  placenta,  may  give 
rise  to  hydramnios.  This  happens,  for  example,  in  cirrhotic 
livers  common  in  syphilitic  children.  There  are  many  other 
conditions  having  the  same  effect — a  cord  abnormally  twisted, 
velamentous  insertion  of  the  cord  (exposing  the  vein  to  external 
pressure),  stenosis  of  the  umbilical  vein,  obstruction  of  the  ductus 
Botalli,*  tumors  of  the  placenta,  tumors,  of  the  fetus  (interfering 
with  its  circulation),  valvular  defects  of  the  heart,  ^  etc. 

((^)  Excessive  excretion  of  urine  is  a  cause  of  hydramnios. 
The  action  of  the  fetal  kidneys  in  the  production  of  hydramnios 
can  best  be  demonstrated  in  cases  of  unioval  twins,  ^  in  one  of 
which  it  is  common  to  find  a  dropsical  amnion,  while  the  other 
one  presents   usually  the   opposite   condition,    oligohydramnios. 

1  Levison,  "  Archiv  f.  Gyn.,"  Bd.  ix,  S.  517;  Lebedjew,  "  Traite  prat,  des 
Ace,"  Charpentier,  1883,  pp.  886,  890. 

^  Winckler  denies  the  existence  of  a  capillary  system  of  blood-vessels  under  the 
amnion,  and  attributes  hydramnios  to  the  presence  of  a  capillary  lymphatic  system  in 
the  cell-layer  of  the  chorion. 

3  "  Ueber  Hydramn.  in  Zusamm.  mit  der  Entstehung  des  Fruchtw.,"  D.  i. 
Zurich,  1875. 

*  Xieberding,  "  Zur  Genese  des  Hydramnios,"  "Archiv  f.  Gvn.,"  Bd.  xx, 
S.  275. 

5  Cordell,  "  Tr.  Med.  and  Chirurg.  Fac.  Maryland,"  1888,  p.  218. 

^  Schatz,  "Archiv  f.  Gyn.,"'  Bd.  xix,  S.  329;  \Verth,  ibid.,  xx,  353;  Sallinger, 
loc.  cit. 


THE  AMNION.  I05 

The  history  of  these  cases  is  that  one  fetus  outstrips  the  other 
in  growth,  and  thus,  acquiring  a  preponderating  influence  in  the 
placenta  which  is  common  to  both,  its  heart  takes  on  a  hyper- 
trophy to  enable  it  to  carry  on  the  greater  part  of  the  placental 
circulation.  The  hypertrophied  heart  produces  in  its  turn  hyper- 
trophy of  the  kidneys  and  determines  their  increased  secretion. 
The  increased  blood-pressure  also  determines  an  increased  activ- 
ity of  the  excretion  from  the  skin,  and  thus  in  a  twofold  manner 
helps  to  increase  the  quantity  of  liquor  amnii. 

[c)  The  fetal  skin  is  a  source  of  hydramnios.  It  can  readily 
be  understood  that  an  increased  blood-supply  from  a  hyper- 
trophied heart  can  stimulate  the  fetal  skin  to  overaction.  There 
are,  however,  more  direct  proofs  of  the  part  that  the  skin  may 
play  in  the  production  of  hydramnios.  Budin  ^  has  described 
a  case  of  hydramnios  associated  with  extensive  nevi,  and  another 
in  which  the  skin  was  thickened  and  thrown  into  folds.  Stein- 
wirker  ^  has  recorded  a  case  of  hydramnios  with  "elephantiasis 
congenita  cystica." 

Finally,  it  is  not  improbable  that  the  amnion  itself  may  take 
an  active  part  in  the  overproduction  of  liquor  amnii  ;  that,  in  other 
words,  the  amnion  may  be  affected  by  acute  inflammation  (amnio- 
titis),  followed  by  an  increased  serous  exudation.  This  supposi- 
tion would  explain  the  cases  in  which  a  blow  or  kick  ^  on  the 
abdomen  of  a  pregnant  woman  is  followed  by  the  development 
of  hydramnios  and  the  formation  of  adhesions  between  the 
fetus  and  the  amnion.  To  amniotitis  has  been  attributed  the 
development  of  acute  hydramnios.  Werth's  *  theory  also  de- 
serves some  consideration  before  leaving  the  study  of  the  fetal 
origin  of  hydramnios.  This  author  believes  that  a  hypertro- 
phied placenta  may  absorb  more  fluid  from  the  maternal  blood 
than  is  required  for  the  fetal  economy  ;  that  the  struggle  to  get 
rid  of  this  excess  of  fluid  brings  about  the  hypertrophy  of  the 
heart  and  kidneys  to  which  reference  has  already  been  made  as 
occurring  especially  in  one  of  unioval  twins. 

III.  Both  Fetus  a7id  Mother  May  Co)itribute  to  the  Produetion 
of  an  Excess  of  Liquor  Amnii. — This  proposition  has  already  been 
demonstrated  in  showing  the  possible  derivation  of  the  liquor  amnii 
from  both  mother  and  fetus.  The  cause  of  the  hydramnios,  how- 
ever, is  most  frequently  found  in  the  fetus,  while  the  combined  ac- 
tion of  both  mother  and  fetus  in  a  single  case  is  rare,  but  may  oc- 
cur, as  in  certain  cases  of  syphilis,  in  which  have  been  found  dropsy 
of  the  mother  and  of  the  fetus  associated  with  hydramnios.'^ 

1  Lot.  cit.  ^  Loc.  cit. 

3  "Tr.  Obstet.  Soc.  of  Baltimore,"  meeting  Feb.  9,  1887.  ■«  Werth,  loc.  cit. 

*  Meissner  and  Hufeland,  fjuotedby  Wilson,  "  Am.  Jour.  Obstetrics,"  1887,  p.  13. 


io6 


FREGXAXCY. 


B.  Hydramnios  may  be  due  to  a  deficient  absorption  of  liquor 
amnii.  The  production  of  liquor  amnii  being  normal,  but  its 
absorption  deficient,  hydramnios  results.  Thus  are  explained  the 
cases  of  h\'dramnios  associated  with  nephritis  and  serous  effusions 
in  the  mother. 

It  has  been  proved  that  the  fetus  swallows  liquor  amnii  in 
considerable  quantities,  and  it  is  possible  that  the  skin  absorbs 
some  of  it.  Whether  the  cessation  of  these  two  functions  results 
in  hydramnios  is  uncertain. 

Symptoms  and  Diagnosis. — The  symptoms  of  h\'dramnios 
are  like  those  of  other  cystic  tumors  in  the  abdomen.  There  is, 
in  addition,  the  history  of  pregnancy  ;  the  tumor  may  usually  be 


Fig.  75- — Abdominal  distention  due  to  hydramnios.      Woman  pregnant  six  months 
with  twins  ;   one  sac  contained  Zy'^  gals.  ;  the  other,  one  pint  (author's  case). 


defined  as  the  uterus,  ver}'  much  larger  than  it  should  be  at  the 
date  that  pregnancy  has  reached  ;  and,  except  in  extreme  cases, 
it  is  possible  to  detect  the  fetal  heart-sounds,  or  to  practice  bal- 
lottement.  As  the  uterus  distends  it  gives  rise,  by  its  increased 
size,  to  pressure  symptoms  in  the  abdomen  and  thorax,  although 
it  is  astonishing  how  large  it  grows  without  seriously  incon- 
veniencing the  patient.  But  this  is  not  the  case  when 
the  liquid  is  rapidly  effused,  as  in  acute  hydramnios.^  The 
woman  suffers  intense  pain  from  the  sudden  distention  of 
the  uterus.  Her  breathing  becomes  labored,  and  complete 
orthopnea   is   developed ;    her   face   is    cyanosed   and   bears    an 

1  Acute  hydramnios  is  rare  :  of  623  cases  of  hydramnios  in  the  Baudelocque  Clinic, 
only  8  were  acute  (Dion,  "These  de  Paris,"  1896). 


THE  AMNION. 


107 


anxious  expression  ;  constant  and  distressing  vomiting  appears, 
and  there  is  fever.  1  The  detection  of  hydramnios  is  not  always 
easy,  and  may  be  practically  impossible.  It  may  be  confused 
with  pregnancy  associated  with  ascites,  or  with  a  cystic  tumor 
of  the  ovary  or  broad  ligament,  or  with  an  ordinary  twin  pregnane}- ; 
or  the  fact  that  the  woman  is  pregnant  may  be  entirely  overlooked. 
This  mistake  has  frequently  led  to  the  tapping  of  the  preg- 
nant womb,  2  which  appears  to  be  harmless.  It  is  possible  to 
mistake  the  overdistended  bladder  associated  with  a  retrofiexed 
gravid  uterus  for  hydramnios.  When  the  dropsy  of  the  amnion 
has  not  reached  an  excessive  degree,  the  distinction  between  it 
and  ascites  with  pregnancy  may  be  made  b\-  mapping  out  the 
uterine  wall  and  detecting  resonance  along  the  flanks  in  the 
dorsal  decubitus  ;  and  an  ovarian  cyst  in  pregnancy  may  be 
excluded  by  the  absence  of  two  tumors  of  different  consistency 
and  shape.  A  twin  pregnancy  without  hydramnios  presents, 
on  external  palpation,  an  enlarged  uterus,  offering  firm  but 
irregular  resistance  from  its  solid  contents.  In  extreme  dis- 
tention of  the  uterus,  which  in  some  cases  seems  limited  only 
by  the  utmost  capacity  of  the  abdomen,  a  definite  diagnosis  is 
impossible ;  in  such  cases  it  is  justifiable  to  resort  to  an  ex- 
ploratory puncture  of  the  membranes  through  the  cervical  canal, 
or  even  to  an  abdominal  section.^ 

Treatment.  —  If  the  fluid  accumulates  in  such  quantity 
or  so  rapidly  as  to  produce  alarming  symptoms  in  the  wo- 
man, its  evacuation  is  indicated.  This  is  best  accomplished 
by  rupturing  the  membranes  through  the  cervix  and  allowing 
the  liquor  amnii  to  escape.  By  this  method  labor  is  induced, 
and  if  the  child  is  not  viable,  its  destruction  is  a  necessar\'  conse- 
quence. Moreover,  the  sudden  gush  of  liquor  amnii  from  the 
uterus  may  induce  syncope  by  the  rapid  reduction  of  intra- 
abdominal pressure,  or  may  result  in  excessive  t}'nipany  from 
the  sudden  relief  of  pressure  on  the  intestines.  It  has,  there- 
fore, been  proposed  (Guillemet,  Schatz)  that  the  uterus  be  tapped 
through  the  abdominal  wall,  and  a  moderate  quantity  of  liquor 
amnii  be  removed  from  time  to  time,  thus  preserving  the  life  of 
the  fetus.  But  the  fetus  in  hydramnios  is  often  deformed  or  dis- 
eased, and  usually  dies  shortl}'  after  birth  ;  its  life,  therefore, 
deserves  little  consideration  in  comparison  with  the  adilitional 
risk  entailed  upon  the  mother  by  puncturing  the  abdominal  and 

1  See  Charpentier,  "  Traite  Prati(]iie  des  Accoucliements." 

2  Cases  reported  by  Scarpa,  Camper,  Noel,  Desmarais,  Scliatz,  Tillaiid,  Cliiara, 
Kidd,  and  others,  not  followed  by  the  slightest  bad  results. 

3  Successfully  performed  in  a  case  of  extreme  distention  of  the  abdomen  fiom 
hydramnios  by  Wilson,  loc.  cit. 


I08  PREGNANCY. 

Uterine  walls.  It  is  especially  in  acute  hydramnios  that  rupture 
of  the  membranes  is  called  for,  irrespective  of  the  age  or  condition 
of  the  fetus. 

Special  instruments  have  been  devised  for  the  perforation  of 
the  membranes,  and  it  has  been  suggested  that  the  puncture  be 
made  at  a  point  far  within  the  uterine  cavity,  and  thus  removed 
from  the  external  os,  so  that  the  liquor  amnii  may  trickle  slowly- 
down  between  the  membranes  and  the  uterine  wall,  and  the 
disadvantages  of  a  sudden  escape  of  the  fluid  be  thus  avoided. 
The  author  usually  employs  an  Emmet  curet  forceps  or  a  Thomas' 
applicator  forceps  to  rupture  the  membranes. 

Abnormalities  of  the  Liquor  Amnii  in  Color,  Consistency, 
and  Chemical  Constitution — The  liquor  amnii,  which  is  nor- 
mally somewhat  opaque  and  whitish  in  color  in  the  last  months 
of  pregnancy,  may  be  green  or  brown  from  the  presence  of 
meconium,  or  it  may  be  tinged  with  red  if  the  fetus  is  macerated. 
The  consistency  of  the  fluid  in  extreme  cases  of  oligohydramnios 
is  that  of  thick  syrup  or  of  mucus.  It  may  contain  sugar  if  the 
mother  has  diabetes  mellitus.  ^ 

Putrefaction  of  the  Liquor  Amnii — Decomposition  of  the 
liquor  amnii  is  most  likely  to  be  associated  with  death  and  putre- 
faction of  the  fetus,  but  an  intensely  putrid  odor  of  the  fluid, 
with  physometra,  has  been  noted  with  a  living  child. 

Adhesive  Inflammation  and  the  Formation  of  Amniotic 
Bands. — Early  in  embryonal  life,  in  case  the  amnion  is  not 
lifted  away  from  the  newly-forming  skin  of  the  embryo,  owing 
to  an  insufficient  secretion  of  amniotic  fluid  or  as  a  conse- 
quence of  inflammation,  adhesions  may  form  between  the 
skin  and  amnion,  and  as  the  amniotic  cavity  is  distended, 
the  adhesive  material  is  stretched,  so  that  it  finally  forms 
bands  of  varying  length  and  thickness,  either  connecting  the 
fetus  with  the  amnion  or  with  one  or  both  ends  detached, 
floating  free  in  the  liquor  amnii.  The  composition  of  these 
bands  closely  resembles  that  of  the  plastic  material  thrown 
out  in  inflammations  of  the  serous  membranes  generally. 
They  are  not  provided  with  blood-vessels.  The  exudation 
of  this  plastic  material  from  the  amnion  results  occasionally  in 
the  formation  of  extensive  adhesions  between  the  fetus  and  the 
amnion,  giving  rise  to  grave  deformities,  as  eventration  or  anen- 
cephalus,  by  preventing  the  proper  arching  over  of  the  walls  of 
the  body-cavities.  The  formation  of  adhesive  bands  is  some- 
times followed  by  intra-uterine  amputations.  A  developing  limb 
may  be  caught  between  two  of  these  bands,  and  as  it  grows  may 

1  Ludvvig,  "  Centralbl.  f.  Gyn.,"  No.  ii,  1S95. 


THE   AMNION. 


109 


be  so  constricted  that  the  distal  portion  of  the  limb  is  entirely  cut 
off  from  its  blood-supply.  Adhesions  may  also  be  formed  between 
various  portions  of  the  body  and  the  amniotic  covering  of  the 
placenta,  or  the  umbilical  cord  may  be  artificially  shortened  Ijy 
the  adhesions  of  coils  one  to  another  and  to  the  fetal  skin/ 


Fig.    76. — Amniotic    bands  :    h,  Adhesive    bands  ;    d,  e,    feet ;  f,  g,  genitalia    and 

anus. 


In  the  latter  part  of  pregnancy  the  amnion  may  burst,  the 
integrity  of  the  ovum  being  preserved  by  the  chorion.  2  The 
fetus  then,  by  its  active  movements,  may  roll  the  amnion  into 
cords,  which  may  become  so  entangled  with  the  umbilical  cord 
as  to  constrict  it  sufficiently  to  obliterate  its  blood-vessels. 

Cysts  of  the  Amnion. — Cases  of  cystic  formations  in  the 
substance  of  the  amnion  have  been  reported  by  Ahlfeld,  Winc- 
kel,  and  Budin.^  They  are  small  and  have  no  clinical  signifi- 
cance. After  the  death  of  the  fetus  the  amnion  undergoes 
certain  changes,  resulting  in  a  loss  of  its  glistening  surface  and 
in  a  considerable  thickening.  The  histology  of  this  change  is 
not  yet  described. 

1  Leopold,  "  Ein  Fotus  niit  Verklelmngen  der  Nabelschnur,''  etc.,  "  Archiv  f. 
Gyn.,"  Bd.  xi,  383. 

''■  Schroeder,  "  Lehrbuch,"  8th  ed.,  p.  455.      Maroger,  '•  1  h&se  dc  Talis,'    1904. 
^  Tarnier  et  Budin,  loc  cit.,  p.  274. 


no 


PREGNANCY. 


THE  CHORION. 

When  the  ovule  first  enters  the  uterine  cavity  and  imbeds 
itself  in  the  thickened  uterine  mucous  membrane,  the  protoplasmic 
cell-wall  of  the  ovum  sends  out  numerous  prolongations,  which 
burrow  into  the  connective  tissue  of  the  decidua,  fix  the  egg  in  its 
position,  and  draw  nutriment  for  the  whole  ovum  from  the  blood- 
vessels of  the  uterine  mucous  membrane.     This  cell-wall,  with 


Fig-   77- — A  young  ovum:    a,  Natural  size;  b,  magnified,  showing  chorionic  villi 

(author's  specimen). 


its  villus-like  projections,  constitutes  the  false  chorion,  which 
soon  disappears  and  is  replaced  by  the  layer  of  cells  springing 
from  the  outer  layer  of  the  blastodermic  membrane  and  surround- 
ing the  whole  ovum  (the  trophoblast) .  This  membrane,  in  its  turn, 
sends  out  branch-hke  processes  (the  vilh  of  the  chorion),  which, 
at  first  non-vascular  but  hollow,  soon  receive  into  the  interior  of 
each  branch  of  the  villi  loops  of  the  blood-vessels  that  have  been 
carried  from  the  fetus  to  the  periphery  of  the  egg  by  the  allantois. 

These  vascular  villi  absorb  nutriment  from  the  whole  ex- 
tent of  the  decidua  reflexa  until  the  third  month,  when  they 
atrophy  and  finally  disappear,  except  at  that  portion  of  the 
periphery  of  the  ovum  which  is  in  direct  contact  with  the  decidua 
vera  (decidua  serotina),  where  the  chorion  villi  develop  still  further 
to  form  the  placenta. 

The  FuIly=deveIoped  Chorion. — Restricting  the  term  chorion 
to  that  portion  of  the  original  membrane  which  undergoes 
atrophy  at  the  third  month  of  pregnancy,  it  is  found  to  con- 
sist  of  a   thin,  transparent  membrane    made   up   of   connective- 


THE    CHORION. 


Ill 


Fig.  78. — Human  embryo  at  the 
third  week,  showing  villi  covering  the 
entire  chorion  (Haeckel). 


tissue   elements   continuous   with  the   substance   of   the   umbili- 
cal cord  and  very  delicate,  atrophied  villi   connecting  it  with  the 
decidua  reflexa.      This  portion  of  the  chorion  is  called  chorion 
laeve  to   distinguish  it  from  the 
chorion    frondosum    that    forms 
the  placenta.     The  fibrous  mem- 
brane, constituting  what  is  usu- 
ally called   chorion   at  term,    is 
derived    from   the   endochorion, 
so  named  to  distinguish  it  from 
the    outer    epithelial    layer   (the 
exochorion),     which     is    to    be 
found  persisting  in  the  epithelial 
covering  of  the  placental  villi. 

Diseases  of  the  Chorion. — 
An  abnormal  condition  of  the 
chorion  is  the  persistence  of  the 
chorionic  villi  around  the  whole 
periphery  of  the  ovum,  thus 
completely  enveloping  the  fetus 
by  the  placenta  (placenta  mem- 
branacea).!  The  degenerations,  aside  from  the  normal  process 
of  atrophy,  that  may  affect  the  chorion  villi  are  of  two  kinds, — 
cystic  and  fibromyxomatous. 

Cystic  degeneration  of  the  chorion  villi  is  characterized 
by  the  hypertrophy  of  the  chorion  villi,  and  their  conversion 
into  cysts  varying  in  size  from  that  of  a  millet-seed  to  the 
size  of  a  grape  or  even  of  a  hen's  ^g%,  connected  with  one  an- 
other and  with  the  base  of  the  chorion  by  pedicles  of  varying 
breadth.  It  is  further  distinguished  by  the  rapid  growth  of  the 
ovum  and  the  consequent  expansion  of  the  uterus,  usually  at 
the  third  to  the  fourth  month  ;  by  the  escape  of  blood  from 
the  uterine  cavity  into  the  vagina,  and  by  the  premature  expul- 
sion of  the  ovum,  which  is  more  or  less  covered  with  numbers  of 
small,  transparent  cysts.  Within  the  cavity  of  the  ovum  may  or 
may  not  be  found  an  embryo. 

This  affection  of  the  chorion,  from  the  peculiar  appearance 
of  the  ovum,  has  attracted  much  attention,  from  the  time  of 
y^tius  von  Ameda  in  the  sixth  century,  and,  from  the  mystery 
that  formerly  surrounded  its  origin  and  the  difference  of  opinion 
that  existed  as  to  its  etiology  and  minute  anatomy,  cystic  degen- 
eration of  the  chorion  villi,  otherwise  known  as  hydatidiform 
mole,  or  dropsy  of  the  chorion  villi,  has  been  the  subject  of 
much  discussion.  First  definitely  described  by  Schenk,  the 
most  extraordinary  theories  have  been  advanced  to  account  for 
1  See  "  Amer.  Jour.  Obstetrics,"  1886,  p.  851. 


112  PREGNANCY. 

its  occurrence/  Regnier  de  Graaf  (1678)  thought  that  each 
vesicle  or  little  cyst  was  an  unfecundated  ovule.  The  belief 
had  once  prevailed  that  each  vesicle  was  a  living  embryo.  ^ 
The  opinion  of  Ruysch  (1691)  and  Albinus  (1754),  that  the  ex- 
istence of  innumerable  little  cysts  in  the  uterus  and  their  final 
expulsion  were  dependent  upon  some  disease  or  alteration  of  the 
ovule,  was  at  last  generally  adopted.  A  more  definite  ex- 
planation was  not  attempted  until,  in  the  early  part  of  the  nine- 
teenth century,  it  was  claimed  by  Percy, ^  Cloquet,^  and  Mme. 
Boivin  ^  that  the  vesicular  disease  was  due  to  echinococci. 
Velpeau  ^  was  the  first  to  indicate  that  the  cysts  were  nothing 
but  distended  chorion  villi.  Since  Velpeau's  announcement, 
cystic  degeneration  of  the  villi  has  been  attributed  to  hyper- 
trophy and  edema  (Meckel,  Gierse)  ;  to  disease  of  the  blood- 
vessels (Bartolin,  Miller,  Cruveilhier)  ;  to  disease  of  the 
lymphatics  (Bidlos,  Sommerring) ;  to  degeneration  of  the 
mucous  substance  within  the  villi,  continuous  with  the  sub- 
stance of  the  cord  (Virchow)  ;  to  a  degeneration  of  the  epi- 
thelial cells  derived  from  the  decidua,  which  replace  the  epi- 
thelial covering  (exochorion)  of  the  chorion  (Ercolani);  to  hyper- 
secretion of  mucus  by  the  cells  of  Langhans'  layer  (von  Franque); 
to  increased  blood  pressure  in  the  fetal  circulation  (Gottschalk); 
and  to  a  pathological  hyperplasia  of  the  syncytium,  with  liquefac- 
tion of  the  epithelial  cells  in  the  interior  of  the  vilh  (Sfameni). 
A  frequent  association  of  the  disease  with  multiple  corpus  luteum 
cysts  in  the  ovary,  an  overproduction  of  lutein  cells  and  their 
infiltration  of  the  ovarian  stroma,  has  been  demonstrated."^  A 
causative  relation  between  the  ovarian  disease  and  the  degenera- 
tion of  the  chorion  has  consequently  been  suspected.  But  the 
same  lutein  cell  hyperplasia  has  been  found  in  normal  gravidae 
and  puerperae  and  has  been  missed  in  cases  of  vesicular  chorion.^ 
Virchow's^  explanation  is  that  the  change  resulting  in  the  cystic 

^  See  "  Tarnier  et  Budin,"  p.  299. 

2  See  the  interesting  quotation  by  Priestley  [loc.  cit.,  p.  36)  from  Ambroise 
Pare,  that  "the  Countess  Margaret  brought  forth  at  one  birth  365  infants,  whereof 
182  were  said  to  be  males,  as  many  females,  and  the  odd  one  a  hermaphrodite" 
(1276  A.  D.).  Pepys  records  in  his  diary  that  he  visited  the  house  in  which  this 
remarkable  delivery  occurred  and  saw  the  brass  platters  on  which  the  children  were 
carried  before  the  bishop  of  the  diocese  for  baptism. 

3  "Jour,  de  Med.,"  t.  xxii,  p.  171,  1811. 

*  No.  I,  "  De  la  Faune  des  Med.,"  Priestley. 

5  "Nouvelles  Recherches  sur  le  Mole  vesiculaire,"  broch.,  Paris,  1827. 

*  "  De  I'Art  des  Accouchements." 

■^  Ludwig  Pick,  "  Centralbl.  fiir  Gyn.,','  No.  34,  1903;  Jaffe,  "Arch.  f.  Gyn.," 
Bd.  70,  H.  3;  Scharlieb,  "  Centralbl.  f.  Gyn.,"  No.  49,  1903;  Stoeckel,  "  Beitr.  z. 
Geb.  u.  Gyn.,"  Festschrift,  1903.  Patellani,  "  Annal.  di  Ostet.  e  Gin.,"  4  and  5, 
1904. 

sWallart,  "  Ztschr.  f.  Geburts.  u.  Gyn.,"  Bd.  liii,  No.  I,  I905. 

'"Die  krankhaften  Geschwiilste,"  Bd.  i,  S.  405. 


THE    CHORION. 


113 


degeneration  of  the  chorion  villi  takes  place  altogether  in  the  endo- 
chorion,  which  forms  the  inner  of  the  two  la}'ers  that  compose  the 
chorion  and  is  continuous  with  the  Wharton  jelly  of  the 
umbiHcal  cord;  this  change  consists  of  the  overproduction 
of  true  mucous  tissue  within  the  villi,  into  which  the  mucous 
tissue  extends  at  first  alone,  but  afterward  accompanied  by 
blood-vessels.  The  process  usually  begins  at  a  time  when  the 
villi  are  almost  equally  developed  over  the  whole  ovum,  that 
is,  before  the  third  month, — and,  therefore,  when  the  vesicular, 
chorion  is  expelled  the  disease  is  usually  found  equally  distributed 
over  the  whole  surface,  showing  no  evidence  of  special  develop- 


Fig.  79. — Cystic  degeneration  of  the  chorion  villi  (  IJumni). 

ment  at  any  one  point  to  indicate  where  the  placenta  would 
have  been  situated.  Involvement  of  the  whole  chorion  is  the 
rule,  but  exceptionally  the  placenta  alone  is  affected,  the  dis- 
ease having  begun  after  the  atrophy  of  the  villi  over  the  extra- 
placental  portion  of  the  chorion.  Still  more  rarely  the  disease 
is  found  in  isolated  spots  upon  the  chorion  laive.^  There  are 
recorded  cases  in  which  one  chorion  of  a  twin  conception  was 
vesicular  while  the  other  remained  normal.      According  to  the 


1  Winogradow,  Virchow's  "  Archiv,"  1S70,  Bd.  li,  .S.  146. 


114 


PREGNANCY. 


foregoing  explanation,  the  disease  is  a  true  myxoma  of  the 
chorion,  and  the  epithehal  ceils  (exochorion)  covering  the  villi 
do  not  necessarily  take  part  in  the  morbid  process,  but  the 
cells  of  Langhans'  layer  and  of  the  syncytium  display  an  ex- 
uberant growth  and  a  decided  inclination  to  penetrate  uterine 
tissue. 

Pathological  Anatomy.  —  The  appearance  of  a  vesicular 
mole  is  peculiar.  The  mass  may  be  as  large  as  a  man's  head, 
covered  more  or  less  completely  with  decidua,  which,  upon 
incision,  or  in  spots  where  the  decidual  covering  is  absent,  reveals 
innumerable  small  cysts,  somxc  as  large  as  grapes,  or  even  as 
hens'   eggs,    connected  with    each    other  or    with    the  base   of 


Fig.    80. — Hydatidiform  mole  (Mc- 
Connell  and  J.  C.  Hirst). 


Fig.,  81. — Hydatidiform  mole,  high 
power,  showing  two  layers  of  cells  (Mc- 
Connell  and  J.  C.  Hirst). 


the  chorion  by  pedicles  of  varying  thickness.  The  liquid 
in  the  cysts  is  usually  clear  and  translucent.  A  microscopic 
examination  of  a  section  through  a  villus  in  the  early  stages  of 
cystic  degeneration  shows  the  distended  cells  of  which  Priest- 
ley speaks,  or  else  there  may  be  seen  the  outer  cellular  and 
inner  fibrous  wall  of  a  villus,  while  within  the  interior  are  stellate 
connective -tissue  cells,  in  the  interstices  between  which  may  be 
found  mucous  tissue. 

The  fluid  in  the  cysts  contains  mucin  and  albumin  in  consid- 
erable quantities. 

Within  the  center  of  the  vesicular  mass  is  usually  found  a 
shriveled  or  distorted  fetus  surrounded  by  its  amnion,  which 
may  contain  an  abnormal  quantity  of  fluid  (hydramnios).  Occa- 
sionally, no  trace  of  the  embryo  is  discovered,  or  at  most  there 


THE    CHORION. 


115 


may  be  seen  only  the  remnant  of  an  umbilical  cord.  More 
rarely  the  fetus,  although  dead,  is  apparently  well  developed  for 
the  date  of  pregnancy,^  and  if  the  degeneration  of  the  chorion 
has  not  been  too  extensive,  a  living,  healthy  infant  may  be  born 


Fig.  82. — Uterus  with  perforating  hydatidiform  mole.  a.  Uterine  veins  and 
chorion  villi;  /',  vessels  of  the  decidua  sercjtina;  c,  internal  os ;  </,  cervix;  v,  eroded 
portions  of  the  uterine  wall  ;  J\  uterine  veins  and  degenerated  churiun  \\\\\.     (i;uniiii.) 

with  a  vesicular  chorion. 2  It  has  been  stated  that  between  the 
ainnion  and  chorion  is  found  a  thin  layer  of  jell}--like  substance 
continuous  with  the  Wharton's  jelly  of  the  umbilical  cord. 
There   is  a  case  on   record  ^  in  whicli  this  substance  formed  a 

1  Priestley,  loc.  cit.,  p.  42. 

2  Schroeder,  "  Lehrbuch  d.  Geb.,"  8th  ed.,  p.  442;  and  Syni,  "  Ivlin.  Med. 
Jour.,"  Aufr.,  1887,  p.  102. 

3  "  Wiener  med.  I'resse,"  1867,  Bd.  i;  and  N'irciiow's  "Archiv,"  I'.d.  xxxix, 
S.  I. 


Il6        •  PREGNANCY. 

layer  four  or  five  millimeters  thick,  originating  from  a  mucous 
degeneration  of  the  connective-tissue  layer  of  the  chorion,  with- 
out involvement  of  the  villi  of  either  the  chorion  laeve  or  fron- 
dosum,  thus  constituting  a  peculiar,  and  to  the  present  time 
unique,  variety  of  myxoma  of  the  chorion. 

The  relation  of  the  cystic  chorion  to  the  two  deciduae 
is  often  abnormal.  Occasionally  the  membranes  retain  their 
normal  relative  position  of  external  deciduae,  median  chorion, 
and  internal  amnion  ;  but  frequently  the  enlarged  villi  of  the 
chorion  perforate  either  one  or  both  deciduae  over  surfaces 
of  varying  extent.  Thus,  specimens  have  been  described^  in 
which  the  cystic  mass  was  inclosed  between  the  decidua  vera 
and  the  reflexa,  or  in  which  the  villi  have  perforated  not  only 
both  deciduEe,  but  also  the  muscular  wall  of  the  uterus,  and 
even  its  peritoneal  covering.^  The  relation  of  myxoma  of  the 
chorion  to  syncytial  cancers  is  quite  intimate.  In  a  large  pro- 
portion of  the  latter  growths  there  is  associated  a  cystic  disease 
of  the  chorion  villi.  Findlay's  statistics^  of  250  cases  of  the 
disease  show  a  development  of  chorion-epithelioma  in  16  per 
cent.  The  cases  formerly  reported  of  malignant  degeneration 
of  the  chorion  were  unquestionably  of  this  character.  There 
may  be  a  metastasis  of  whole  chorion  villi,  without  a  malignant 
degeneration  of  the  epithelial  cells,*  or  the  chorion  epithelium 
may  undergo  malignant  degeneration  after  metastasis.^ 

Clinical  History  and  Diagnosis. — There  are  three  prominent 
symptoms  associated  with  the  cystic  degeneration  of  the  chorion  : 
(i)  Rapid  increase  in  the  size  of  the  uterus;  (2)  discharge  of 
blood  or  bloody  serum,  and  (3)  the  escape  of  vesicles.  The 
last  symptom  is  of  rare  occurrence,  and  the  first  two  do  not 
always  manifest  themselves  in  a  typical  manner,  so  that  the 
clinical  phenomena  in  a  case  -  of  vesicular  mole  do  not  always 
permit  of  a  definite  diagnosis.  If  there  is  an  escape  of  blood 
at  intervals  during  the  early  part  of  pregnancy,  if  the  uterus 
rapidly  enlarges  toward  the  third  month,  and  if  careful  palpa- 
tion elicits  no  sign  of  the  presence  of  a  fetus  within  the  uterine 
cavity,  the  existence  of  a  cystic  chorion  may  be  suspected.  If, 
as  rarely  happens,  characteristic  cysts  are  expelled,  there  can  be 
no  doubt  as  to  the  nature  of  the  case.     The  sudden  distention 

1  Priestley,  loc.  cit.,  p.  40. 

2  Cory,  quoted  by  Priestley,  p.  41.  Volkmann,  Waldeyer,  Jarotzky,  Kriegei, 
Wilton,  quoted  by  Schroeder,  op.  cit.,  p.  444- 

^  "Am.  Journ.  Med.  Sci.,"  March,  190.^. 

4Gaylord,  "Tr.  of  the  Gyn.  Section,  College  of  Physicians  of  Phila.,"  1898. 

5  Zagorjanski-Kissel,  "  Ueber  das  primare  Chorioepitheliom  ausserhalb  des 
Bereiches  der  Ei-ansiedelung,"  "Arch.  f.  Gyn.,"  Bd.  Ixxvi,  H.  2;  also  "  Ueber 
das  Chorioepitheliom  in  der  Vagina  bei  sonst  gesundem  Genitale,"  Monograph, 
Hiibl,  Wien,  1903. 


THE    CHORION. 


117 


of  the  uterus  usually  causes  distressing  nausea  and  vomiting. 
Occasionally,  after  the  development  of  the  chorion  villi,  the  dis- 
ease is  arrested  and  the  ovum  is  retained  for  many  months,  so 
that  in  such  cases  there  may  be  all  the  symptoms  of  pregnancy, 
with  a  previous  history  of  bleeding,  but  the  womb  at  the  time 
of  examination  is  much  smaller  than  it  should  be  at  the  date 
which  the  pregnancy  has  apparently  reached.  Vesicular  mole 
is  most  apt  to  occur  in  women  who  have  already  borne  children 
or  who  have  reached  middle  age.  Hirtzmann  ^  found  that,  of 
35  cases,  25  occurred  in  women  over  twenty-five  years  of  age. 
As  an  exception  to  this  rule,  Strieker^  reports  a  case  of  pre- 
cocious menstruation  in  a  child  who  in  her  ninth  year  gave  birth 
to  a  true  vesicular  mole.  It  is  hardly  necessary  to  state  that 
cystic  degeneration  of  the  chorion  villi  is  necessarily  a  result 
of  impregnation,  and  can  not  occur  in  a  virgin  uterus.  In  100 
cases  collected  by  Borland,^  68  occurred  between  the  twentieth 
and  fortieth  year.  In  210  cases  collected  by  Findley,*  the  average 
age  was  twenty- seven;  the  extremes  were  thirteen  and  fifty- 
eight  years.  Cystic  degeneration  of  the  chorion  often  occurs 
in  women  who  have  previously  given  birth  to  healthy  children, 
but  it  not  infrequently  recurs  in  the  same  individual.  Depaul  ^ 
mentions  a  woman  who  had  this  affection  three  times,  and  Mayer  " 
has  observed  the  disease  in  eleven  successive  pregnancies.  The 
degenerated  chorion  usually  determines  the  expulsion  of  the 
ovum  at  some  period  between  the  third  and  sixth  months  of 
gestation.  If,  however,  the  disease  does  not  begin  until  after 
the  villi  of  the  chorion  laeve  have  atrophied,  or  if  the  degeneration 
is  confined  to  a  comparatively  hmited  area,  the  pregnancy  usuallv 
proceeds  to  term.  But,  if  the  embryo  is  absorbed  and  the  chorion 
becomes  adherent  to  the  uterine  wall,  the  pregnancy  may  be 
abnormally  prolonged  to  twelve  or  thirteen  months  (Schroeder). 
The  adhesion  of  the  cystic  villi  to  the  uterine  wall  has  more  serious 
results  than  the  mere  prolongation  of  pregnancy.  It  is  often  due 
to  the  perforation  of  the  uterine  wall  by  a  proliferation  of  the  syncy- 
tial cells  of  the  chorion  villi,  and  consccjuently  when  the  mass  is  ex- 
pelled there  may  be  fatal  hemorrhage  from  the  uterine  sinu.scs 
(Volkmann,  Waldeyer),  or,  as  in  Wilton's  case,**  the  peritoneal 
covering  may  be  torn  and  fatal  hemorrhage  may  ensue  into  tlie 
peritoneal  cavity.      The  retention  of  a  portion  of  the  chorion  may 

1  "  Th^se  tie  Paris,"  1874.  ^  Virchcnv's  "Arcliiv,"  Bd.  Ixxvii,  .S.  193. 

3  "Am.  Journ.  of  Obstet.,"  1896,  p.  905. 
*  "Am.  Journ.  of  Obstet.,"  Marcli,  1903. 

5  "  Legons  de  Clin.  Obst.,"  1872.  •*  "  Tarnier  et  Budin,'"  p.  306. 

'  In   Doiland's  loo  cases  the  mass  was  expelled  in  63  jier  cent,  between  the 
third  and  fifth  months. 

**"  Lancet,"  Feb.,  1 840. 


Il8  PREGNANCY. 

be  followed  by  its  decomposition  within  the  uterine  cavity,  giving 
rise  to  general  septicemia  ;  or  fragments  of  cystic  chorion  retained 
in  utero  may  be  expelled  at  a  date  remote  from  the  original  preg- 
nancy. With  these  accidents,  of  not  infrequent  occurrence  in  the 
course  of  the  disease,  it  is  not  surprising  that  the  maternal  mor- 
tality is  eighteen  to  twenty- five  per  cent/ 

Etiology  and  Frequency, — The  occurrence  of  vesicular  disease 
of  the  chorion  can  not  be  attributed  to  any  single  cause.  The 
connection  between  disease  of  the  endometrium  (Virchow)  or 
of  the  uterine  walls  (fibroid  tumor  (Schroeder)  )  and  vesicu- 
lar mole  is  clearly  established  in  a  large  proportion  of  the 
cases,  especially  in  those  in  which  there  is  a  frequent  recurrence 
of  the  disease  ;  but  this  explanation  does  not  suffice  for  the 
degeneration  in  the  chorion  of  one  fetus  while  that  of  its  twin 
remains  healthy.  In  this  .case  the  disease  is  of  fetal  origin, — per- 
haps the  result  of  the  death  of  the  fetus.  Indeed,  it  has  been 
claimed  that  the  death  of  the  embryo  necessarily  precedes  the 
cystic  degeneration  of  the  chorion.  That  this  view  is  incorrect 
is  demonstrated  by  the  birth  of  living  children  in  cases  of  not 
too  extensive  degeneration  of  the  chorion.  It  has  been  claimed 
that  vesicular  mole  is  the  result  of  absence  of  the  allantois 
(Hecker),  or  that  possibly  the  allantois  may  contain  no  blood- 
vessels (Schroeder),  thus  depriving  the  villi  of  their  blood- 
supply. 

Stenosis  of  the  umbilical  vein  has  been  found  associated 
with  cystic  chorion,  and,  therefore,  it  has  been  asserted  that  the 
cystic  degeneration  may  have  been  due  to  dropsy  of  the  chorion 
vilh  (Maslowski,  Robin).  A  pathological  hyperplasia  of  the 
syncytium,  possibly  stimulated  by  an  overgrowth  of  lutein  cells 
in  the  ovary,  followed  by  liquefaction  of  the  cells  in  the  interior, 
is  the  latest  and  most  generally  accepted  theory  to  account  for 
the  disease.  As  to  the  frequency  of  this  affection,  there  are  no 
reliable  statistics.  Mme.  Boivin  ^  saw  the  disease  only  twice  in 
20,37c;  pregnancies,  while  in  the  Charite  in  Berlin  it  occurred 
four  times  in  2130  pregnancies.  Eight  cases  have  been  under 
my  care  in  twenty  years.  Every  obstetrician  of  large  practice  has 
seen  at  least  one  case.  Cystic  degeneration  of  the  chorion  villi 
occurs  probably  once  in  two  or  three  thousand  pregnancies. 

The  treatment  is  mainly  symptomatic.  In  cases  of  hemop 
rhage,  it  may  be  necessary  to  tampon  the  vagina  until  the  os 
is  sufficiently  dilated  to  permit  the  expulsion  of  the  cystic  mass, 
or  its  extraction  by  the  fingers,  or  by  placental  forceps.  If  the 
diagnosis  of  cystic  disease  of  the  chorion  is  made  during  preg- 
nancy,   and    if    abdominal    or    combined    palpation    gives    no 

1  Borland,  loc.  cit.;  Findley,  loc.  cit.  ''■  "Clin.  Mem.,"  1S63. 


THE    CHORION.  1 19 

signs  of  the  presence  of  a  fetus,  the  immediate  induction  of 
abortion  is  advisable  so  that  the  chorion  shall  not  reach  an 
inordinate  size  and  penetrate  the  uterine  wall,  causing  hemor-  • 
rhage  or  possibly  perforation  of  the  uterus.  A  prolonged  re- 
tention of  the  mass  also  predisposes  to  malignant  degenera- 
tion of  its  epithelium.  After  the  expulsion  of  the  diseased  ovum, 
if  there  are  symptoms  pointing  to  the  retention  and  decompo- 
sition of  fragments  of  the  chorion  within  the  uterine  cavit}',  tlie 
natural  impulse  would  be  to  remove  the  retained  substances  ; 
but  it  must  be  borne  in  mind  that  the  attenuation  of  the  uterine 
wall  in  circumscribed  areas  may  be  so  great  that  the  slightest 
interference,  the  introduction  of  a  curet,  or  the  administration 
of  an  intra-uterine  douche,  may  cause  its  rupture  with  a  fatal 
result.  ^ 

The  uterus  should  be  packed  with  gauze  after  its  evacuation 
to  stimulate  its  contraction  and  to  control  hemorrhage.  The 
patient  should  be  kept  under  observation  for  months  and  years. 
If  there  is  a  tendency  to  metrorrhagia  there  should  be  a  micro- 
scopic examination  of  endometrium  removed  by  curettage.  If 
evidence  of  chorion-epithelioma  is  discovered,  a  hysterectomy  is 
urgently  indicated. 

Rupture  of  the  Chorion. — Both  the  amnion  and  chorion  may 
rupture,  without  terminating  pregnancy.  The  fetus  either  re- 
mains within  the  amniotic  cavity  or  escapes  from  its  ovular 
envelopes  and  continues  its  development  in  direct  relationship 
with  the  deciduse  (extramembranous  development^). 

Fibromyxomatous  Degeneration  of  the  Chorion. — If  fibrous  tis- 
sue predominates  between  the  degenerated  villi,  the  mass  is 
solid  instead  of  cystic.  Virchow  ^  first  called  attention  to  this 
condition  in  the  placenta,  and  gave  it  the  name  of  myxoma 
fibrosum  placentae.  In  the  midst  of  healthy  cotyledons  one 
was  discovered  affected  by  a  fibromucous  degeneration,  A 
similar  structure  may  be  found  in  the  peripheral  la>'ers  of  the 
umbilical  cord. 

To  complete  the  study  of  diseases  of  the  chorion  it  is 
necessary  to  mention  a  chronic  inflammation  of  the  membrane.  ^ 
In  the  case,  already  referred  to,  in  which  the  amnion  was  rup- 
tured during  pregnancy,  the  irritating  effect  of  the  liquor  amnii 
upon  the  chorion  produced  a  thickened  and  hj-perjilastic  con- 
dition of  that  membrane. 

1  For  a  case  resulting  fatally  after  the  injection  of  ]-.erchlorid  of  iron,  sec  V\\v>v 
ley,  loc.  cit.,  p.  41.  .       . 

2  Maroger,  "These  de  Paris,"  1904.  Op.  cil.,  b.  414. 
*  Lebedeff,  quoted  by  Tarnier,  op.  tit.,  p.  313. 


I20 


PREGNANCY. 


THE  PLACENTA. 


The  placenta,  as  a  separate  organ,  dates  from  the  third  month 
of  pregnancy.  At  this  time  the  chorion  villi  atrophy  over  the 
whole  periphery  of  the  ovum,  except  at  the  point  where  it  comes 


Fig.  83. — The  fetal  surface  of  the  placenta  (Minot). 

in  direct  relation  with  the  true  mucous  membrane  of  the  uterus — 
the  decidua  serotina.  Here  the  villi  take  on  an  extraordinary 
growth,  forming  buds  of  epithelial  cells  (syncytium)  upon  their 
surface,  which  rapidly  take  on  the  shape  of  new  villi,  thus  send- 
ing out  branches  in  every  direction,  into  each  of  which  a  loop 
of  blood-vessels  is  projected.  Separating  the  villi  from  one 
another,  and  dipping  down  to  the  base  of  the  chorion  between 


THE   PLACENTA.  121 

the  parent  stems  of  the  villous  projections,  are  processes  of  the 
decidua,  carrying  capillary  loops  of  maternal  blood-vessels. 
Very  early  in  the  history  of  the  ovum  ^  the  arterioles  of  this  sys- 
tem open  directly  into  the  intervillous  spaces  of  the  placenta, 
so  that  the  placental  villi  are  bathed  directly  in  maternal  blood. 
So  far  almost  all  authorities  are  agreed,  but  as  to  the  relation 
of  the  terminal  villi  to  the  uterine  mucous  membranes,  the  action 
of  the  chorional  and  decidual  epithelium,  the  changes  that 
convert  the  uterine  capillaries  at  first  surrounding  the  villi  into 
the  large  blood-sinuses  that  are  later  found  in  the  placenta, 
many  conflicting  theories  have  been  advanced.  As  to  the  rela- 
tion between  the  placental  villi  and  the  uterine  mucous  mem- 
brane, it  has  been  variously  stated  that  the  former  enter  the 
mouths  of  the  uterine  glands  (Bischoff) ;  that  they  sink  into 
crypts  in  the  uterine  mucous  membrane,  which  are  new  forma- 
tions especially  adapted  for  their  reception  (Turner);  that  the 
villi  do  not  sink  into  glands  or  crypts,  but  are  intimately  invested  ■ 
with  a  layer  of  decidual  epithelium,  or  with  an  endothelial  cover- 
ing derived  from  the  maternal  blood-vessels  (Ercolani);  and  that 
this  cell-covering  acts  as  a  glandular  structure,  secreting  from 
the  maternal  blood  a  peculiar  substance,  the  so-called  "uterine 
milk,"  which  acts  as  nutriment  for  the  fetal  blood  (Ercolani, 
Hoffman),  It  is  now  well  established,  however,  that  the  placental 
villi  imbed  themselves  in  the  soft  interglandular  substance  of  the 
decidua  serotina,  often  projecting  into  the  mouth  of  the  small 
veins,  and  that  the  connective-tissue  cells  multiply  and  hyper- 
trophy around  them  (decidual  cells).  The  epithelium  of  the 
uterine  mucous  membrane  disappears,  except  in  the  glands.  The 
chorion  villi  are  at  first  covered  with  two  distinct  layers  of  cells; 
an  inner  layer  composed  of  single  large  nucleated  cells  arranged 
side  by  side  with  distinct  cell  walls  (Langhans'  layer),  and  an  outer 
layer  or  band  of  protoplasm  in  which  are  imbedded  nuclei  at 
irregular  intervals  (the  syncytium).  Both  of  these  layers  are 
derived  from  the  chorion  and  not  from  the  uterine  epithelium  or 
the  endothelium  of  the  uterine  blood-vessels.  Early  in  embryonal 
Hfe  (the  third  month)  the  Langhans  layer  disappears  and  the  syn- 
cytium remains  as  the  sole  epithelial  covering  of  the  villi.  In 
the  youngest  ova  yet  observed  the  trophoblast  contains  lacunae 
to  which  blood  is  conveyed  from  the  maternal  circulation  by  little 
curling  arteries  that  wind  their  way  up  through  the  decidual  cells 
to  empty  directly  into  the  placental  sinuses.  These  arteries  are 
provided  with  only  a  delicate  endothelial  wall.     From  Leopold's - 

1  In    Leopold's    ovum    of  seven   to  eight   days   this  arrangement  was  already 
visible.     "  Uterus  u.  Kind,"  Leipsic,  1897. 
^  Loc.  cit. 


122 


PREGNANCY. 


observations  it  appears  that  the  arterioles  of  the  decidua  become 
more  and  more  distended  as  they  approach  the  placental  villi, 

so  that  their  terminal 
expansions  m.ay  be  com- 
pared to  a  sea  into  which 
project  peninsulas  and 
capes  of  decidual  masses 
and  placental  villi.  The 
syncytial  cells  of  the 
latter  have  the  power  to 
penetrate  the  endothe- 
lium of  the  decidual  ar- 
terioles and  thus  open 
a  direct  communication 
between  the  placental 
villi  and  the  maternal 
blood.  By  this  ana- 
tomical arrangement 
the  fetal  and  maternal 
blood  is,  of  course,  kept 
separate.  The  former  circulates  within  the  capillary  system  of 
the  villi;  the  latter  bathes  the  exterior  of  the  villi. 


Fig.  84. — The  capillary  system  of  a  placental  villus 
(from  Minot). 


Fig.  85.. — Section  of  placental  villi  of  a  normal  placenta  at  term:  M,  Fetal 
mesoderm ;  S,  syncytial  masses ;  V,  V^,  fetal  vessels ;  L,  maternal  lacuna,  con- 
taining maternal  blood  (Durante). 


The  Funy=developed  Placenta. — The  placenta  at  term  is 
a  circular  mass,  measuring  about  seven  inches  in  diameter, 
about  two-thirds  of  an  inch  to  an  inch  in  thickness  at  the  point  of 
insertion  of  the  cord,  and  weighing  about  sixteen  ounces.    Upon 


THE   PLACENTA. 


123 


Fig.  86. — A,  Placenta  in  its  most  generalized  form  ;  B,  structure  of  placenta  of 
pig;  C,  structure  of  placenta  of  cow  ;  D,  structure  of  placenta  of  fox;  E,  structure 
of  placenta  of  cat ;  F,  structure  of  placenta  of  sloth  ;  on  the  right  side  of  the  figure 
the  flat  maternal  epithelial  cells  are  shown  in  situ  ;  on  the  left  side  they  are  removed, 
and  the  dilated  maternal  vessel  with  its  blood-corpuscles  is  exposed  ;  G,  structure  of 
human  placenta;  F,  fetal,  and  Af,  maternal  placenta;  f,  epithelium  of  chorion; 
X,  epithelium  of  maternal  placenta ;  </,  fetal  blood-vessels ;  ti',  maternal  blood- 
vessels;  V,  villus.  The  succeeding  references  apply  to  G  only:  ds,  Decidua  serotina 
of  placenta ;  t,  trabeculse  of  serotina  passing  to  fetal  villi;  ca,  curling  artery;  uf, 
uteroplacental  vein  (from  Balfour,  after  Turner). 


124 


PREGNANCY. 


the  surface  of  the  placenta  into  which  the  cord  enters  is  seen, 
a  smooth,  shining  membrane,  continuous  with  the  sheath  of  the 
cord, — the  amnion.  The  fetal  side  of  the  placenta  contrasts 
strongly  with  the  maternal  surface.  The  latter  is  of  a  dark-red 
hue,  divided  by  deep  sulci  into  lobules  of  irregular  outline  and 
extent, — the  cotyledons.  Over  the  maternal  surface  of  the  pla- 
centa is  stretched  a  delicate,  grayish,  transparent  membrane, 
which  is  made  up  of  the  cells  that  compose  the  upper  layer  of  the 
decidua  serotina.  This  constitutes  the  maternal  portion  of  the 
placenta.  In  separating  from  the  uterine  wall,  therefore,  the  line 
of  separation  does  not  divide  the  fetal  from  the  maternal  struc- 
tures, but  is  found  in  the  mucous  membrane  of  the  uterus,  in  the 
lower  portion  of  the  cellular  layer  of  the  decidua.  Around  the 
periphery  of  the  placenta  may  be  seen  a  large  vein,  the  circular 
vein  of  the  placenta,  which  returns  a  part  of  the  maternal  blood 
from  the  organ,  the  remainder  returning  to  the  maternal  circula- 
tion by  means  of  the  continuity  between  the  placental  lacunae 
and  the  uterine  sinuses.      The  situation  of  the  placenta  within  the 


/"-^  *^~>  ^-- 


',fN.'<,..*'^:.xv<^ 


"i:- 


m(^ 


C^J 


Fig.  87. — Surface  of  villus  at  three  weeks,  showing  syncytial  band,  A,  and 
Langhans'  cells,  B  (500  enlargementj  ;   C,  stroma  of  villus. 

uterus  may  with  equal  frequency  be  found  upon  the  posterior 
or  the  anterior  wall  ;  occasionally,  however,  upon  one  of  the 
lateral  walls,  more  frequently  the  right. 

A  perpendicular  section  through  the  middle  of  a  placenta 
that  is  still  attached  to  the  uterine  wall  reveals  an  intimate 
connection  between  the  two.  The  delicate  terminal  villi,  and 
even  branches  a  millimeter  in  thickness,  are  imbedded  in  the 
upper  portion  of  the  decidua,  and  held  in  place  by  their 
extremities  bulging  out  into  club-shaped  masses,  so  that  the 
exercise  of  considerable  force  will  not  extract  them  from  the 
uterine  mucous  membrane,  but  will,  instead,  always  lacerate 
the  maternal  structures. 


THE   PLACEXTA. 


125 


The  functions  of  the  placenta  are  manifold.  Xot  only  docs  it 
act  as  a  lung,  or,  rather,  gill,  in  ox\'genating  the  fetal  blood, 
but  it  may  be  said  to  take  the  place  of  the  alimentar}-  tract 
in  absorbing  nutritive  material  from  the  maternal  circulation. 
It  plays,  moreover,  the  part  of  an  excretorx'  organ,  getting 
rid  of  the  surplus  carbonic  acid  gas  in  the  fetal  blood  and 
of  the  other  waste-products  of  tissue-activity.  Bernard  has 
shown  that  in  the  earlier  months  of  pregnancy  the  placenta 
has  a  glycogenic  function.  The  epithelial  cells  of  the  chorion 
villi  exercise  selection  in  the  passage  of  substances  between 
the  fetal  and  the  maternal  blood.  Some  pathogenic  micro- 
organisms— as,  for  instance,  those  of  variola — pass  easily  from 
mother  to  fetus,  while  the  bacilli  of  tuberculosis,  a  disease  often 
present   in   pregnant   women,    are    almost    never   found    in   the 


Fig.  88. — Diagram  of  uterus  and  placenta  in  the  fifth  month  :  Ch,  Chorion  ; 
am,  amnion;  V,  V,  villi;  Z,  Z,  lacunae;  s,  serotina;  v,  small  arteries;  /,  glandu- 
lar layer;  vi,  uterine  muscle  (Leopold). 


fetus.  Certain  drugs,  also  (iodid  of  potassium,  benzoic  acid, 
bichlorid  of  mercury),  enter  the  fetal  from  the  maternal  blood, 
whilfe  it  is  asserted  that  others,  as  woorara,  will  not  pass  to  the  fetus 
from  the  mother.  Again,  while  nutriti\'e  material  must  pass 
from  mother  to  fetus,  the  escape  of  the  same  material  from  the 
fetal  into  the  maternal  blood  would  pro\-e  destructi\'c  to  the  tetus. 

Anomalies  of  the  Placenta. — The  placenta  ma\^  present  de- 
viations from  the  normal  in  size,  position,  shape,  weight,  or  num- 
ber. Its  structure  may  present  anomalies  the  result  of  diseases 
or  accidents,  and  there  may  be  anomalies  of  function. 

Anomalies  of  Position,  Size,  and  Weight. — The  position  of  the 
placenta  is   normal!}'   near  the  fundus   uteri.       A   low  insertion 


126 


PREGNANCY. 


is  a  cause  of  placenta  pravia.  The  size  of  the  placenta  varies 
considerably.  Its  thickness  is  in  inverse  ratio  to  its  extent, 
and  the  younger  the  ovum,  the  greater  the  relative  size  of  the 
placenta.  The  placenta  has  been  known  in  rare  cases  to  extend 
around  the  whole  periphery  of  the  ovum.  This  condition  is 
called  placenta  membranacea,  and  is  explained  b}'  the  equal  de- 
velopment of  all  the  chorional  villi.  The  placenta  may  be 
abnormally  thick  and  enlarged  in  all  directions,  from  the  hyper- 
plasia due  to  a  chronically  inflamed  endometrium.  An  abnorm- 
ally small  placenta  may  be  associated  with  an  ill-developed  child, 
may  depend  upon  an  interstitial  overgrowth  with  subsequent  re- 
traction, or  may  be  due  to  atrophy  of  the  decidua. 


Fig.  89. — Placentae  of  triplets. 

Anomalies  of  Shape  and  Number. — The  placenta,  usually  round 

or  oval,  may  have  a  horseshoe  or  crescentic  shape,  especially 
if  it  is  inserted  near  the  internal  os,  ^^vhich  is  surrounded  by 
the  two  arms  of  the  crescent.  In  multiple  pregnancies  (not 
unioval)  each  child  has  its  own  placenta  (Fig.  89).  A  single 
child  may  have  two  (placenta  duplex),  three  (placenta  tripartita), 
or  more  placentae  ("placenta  multiloba),  or  a  single  placenta  may 
be  reinforced  by  one  or  more  small  accessory  placental  develop- 
ments (placentae  succenturiats),  which  are  in  direct  communi- 
cation with  the  blood-sinuses  of  the  decidua  vera.  If  the 
villi  of  these  accessory  growths  do  not  communicate  with  the 
maternal  blood,  they  are  called  placentae  spuria^.  Taurin  ^  has 
1  '^Nouv.  Arch.  d'Obstet.,"  1893.  p.  486. 


PLATE  3. 


Anomalies  of  the  Placenta:  I,  Placenta  with  irregular  lobes  (Auvard)  ;  2  placenta  in 
two  unequal  lobes  (Auvard);  3,  irregular  placenta  (Auvard);  4,  small  accessory  placenta 
(Ribemont-Lepage)  ;  5,  placenta  succenturiata  (Ribemont-Lepage)  ;  6,  "battledore" 
placenta,  oval  (Auvard)  ;  7,  placenta  with  velamentous  attachment  of  cord  (Ribemont- 
Lepage)  ;  8,  placenta  with  two  equal  lobes  (Ribemont-Lepage). 


THE   PLACENTA.  12/ 

reported  a  case  of  annular  placenta,  extending  almost  completely 
around  the  ovum  as  it  does  in  some  animals,  but  separated  indis- 
tinctly into  three  lobes. 

Edema  of  the  Placenta. — A  serous  infiltration  of  the  whole 
placenta  is  often  observed  with  a  dead  and  macerated  fetus/ 
The  same  condition  is  often  associated  with  general  anasarca  of 
the  fetus,  with  some  obstruction  of  the  umbilical  vein  or  of  the 
venous  system  of  the  fetus,  or  with  a  greatly  hypertrophied  pla- 
centa which  absorbs  more  fluid  than  the  fetal  economy  can  dispose 
of  (Werth).  The  minute  anatomy  of  the  placenta  may  remain 
normal  in  this  disease  and  the  placenta  may  continue  to  perform 
its  physiological  functions. 

Degeneration  of  the  Placental  Villi. — The  morbid  processes 
abrogating  the  physiological  activity  of  the  placental  villi  are 
hypertrophy  ;  fibrous  and  fatty,  caseous  (phthisical  placenta), 
calcareous,  and  myxomatous  degenerations.  Placental  hemor- 
rhages, placental  syphilis,  and  solid  tumors  of  the  placenta  have, 
as  a  result,  the  destruction  of  all  or  a  part  of  the  placental  villi 
as  factors  in  the  nutrition  and  aeration  of  the  fetal  blood,  but 
these  conditions  are  considered  separately. 

"Placental  infarcts,"  so  commonly  seen  as  whitish  nodes  in 
the  majority  of  placentae,  are  examples  of  a  fibrous  degeneration 
due,  according  to  Williams,  to  an  endarteritis  of  the  vessels  of  the 
villi,  a  coagulation-necrosis,  and  the  formation  of  canalized  fibrin.^ 

Myxomatous  Degeneration. — The  myxomatous  degeneration 
that  has  already  been  studied  in  the  chorion  villi  may  be  confined 
to  the  placenta,  while  the  extraplacental  chorion  remains  healthy. 
Myxoma  fibrosum  placentce  has  been  described  by  Virchow,* 
Storch  (two  cases), ^  Hildebrandt,^  and  Sinclair.^ 

Calcareous  Degeneration. — Depositions  of  small  quantities  of 
lime  in  the  placenta  are  not  at  all  uncommon.  They  are  usually 
to  be  found  in  that  portion  of  the  maternal  placenta  lying  nearest 
the  vilH,  or  they  may  originate  in  the  villi  themselves.  Cham- 
bord^  has  found  as  many  as  five  hundred  concretions  in  one 
placenta.  It  has  been  said  that  extensive  calcification  of  the  pla- 
centa is  more  apt  to  occur  after  the  death  of  the  fetus,  but  Tar- 
nier  asserts  that  there  is  no  relation  of  cause  and  effect  between 
the  two,  and  that  the  occurrence  of  large  calcareous  deposits  in 
the  placenta  with  still-born  children  is  a  mere  coincidence,  as  it 

1  Tarnier  et  Budin,  op.  ciL,  p.  329. 

'■^  "  The  Freriuency  and  Significance  of  Infarcts  of  the  Placenta,  Based  upon  the 
Microscopic  Examination  of  500  Consecutive  Placenta;,'  Whitridge  Williams,  Johns 
Hopkins  Hosp.  Rep.,  vol.  ix. 

■'  Lpc.  cjt.,  p.  414. 

*Virchow's  "  Archiv,"  1878;  and  Breus'  "Wien.  med.  Wochens.,"'  18S1,  No.  40. 

*  "  Monat.  f.  Geb.,"  Bd.  xxxi,  S.  346.        ^ "  Jour.  Ubstct.  Soc,"  Boston,  1S71. 

'  "  Lyon  Medicale,"  1873,  p.  431. 


128 


PREGNANCY. 


is  also  in  cases  in  which  calcareous  degeneration  is  associated 
with  syphilis.^ 

In  1873  Frankel  claimed  to  be  the  first  to  demonstrate  that 
the  "deforming  granular  hyperplasia  and  hypertrophy  of  the  pla- 
cental vilh,"  described  by  Ercolani,  without  reference  to  its  con- 
nection with  syphilis,  was  the  most  frequent  form  of  placental 
syphihs.^ 

According  to  Frankel,  this  infiltration  of  the  villi  with  granula- 
tion-cells, and  their  consequent  increase  in  size  and  distorted 
shapes,  are  characteristic  of  syphilis.  The  seat  and  extent  of  the 
lesion  vary  with  the  manner  and  time  of  the  fetal  infection.     If  the 


Fig.  90. — Section  of  villi,  showing  small-cell  infiltration  and  the  deformed  shapes 
of  villi :  A, A,  Luxuriant  cell-development  in  the  interior ;  V,  V,  lumen  of  blood-vessels 
with  hypertrophied  walls  ;  B,  villus  in  which  only  a  trace  of  blood-vessels  can  be  seen  at 
S;  C,C,  villi  without  trace  of  vascular  canal ;  D,D,D,  epithelial  covering  (Frankel). 

ovule  is  infected  by  the  impregnating  spermatic  particle,  the 
placenta,  if  diseased  at  all,  constantly  presents  the  granulation- 
cell  infiltration  of  the  villi  and  the  degeneration  of  their  epitheUal 
covering.  If  the  mother  is  infected  during  the  fruitful  coitus,  there 
may  be  endometritis  placentaris,  characterized  by  an  enormous 
overgrowth  of  the  decidual  cells  or  the  overgrowth  of  connective 
tissue  as  well  as  syphilitic  disease  of  the  villi.  If  the  mother  is 
syphiUtic  before  conception,  the  disease  of  the  placenta  takes  the 
form   of   endometritis   placentaris   gummosa.     If   the   mother   is 

i.See  al^o   Frankel,    "  Archiv   f.    (Jyn.,"    Bd.    ii,  S.   373;   Wincklei,  "  Archiv  f. 
Gyn.,"  Bd.  iv,  S.  260;    Langhans,  "Archiv  f.  Gyn.,''  Bd.  iii,  S.  150. 
^"  Ueber  Flacentar  Syphilis,"  "  Archiv  f.  Gyn.,"  Bd.  v,  S.  6. 


THE   PLACENTA. 


129 


infected  during  the  latter  months  of  pregnancy,  the  placenta  usu- 
ally remains  unaffected.  Frankel  bases  these  conclusions  upon 
the  examination  of  more  than  one  hundred  specimens,  and  his 
views  have  been  confirmed  by  Hening  and  McDonald.  Federoff,^ 
on  the  contrary,  declares  that  Frankei's  disease  is  not  constant. 
Efforts  to  find  the  spirochaeta  pallida  in  the  placentae  of  syphihtic 
fetuses  have  met  with  variable  results.  Cappellani  failed  in  three 
cases.  Guicciardi,  Mohn,  Wallich,  Levaditi,  Nathan,  Larrier, 
Brindeau,  and  others  have  succeeded." 

In  their  macroscopic  appearances  syphilitic  placentae  m.ay 
differ  considerably.  If  the  child  has  been  dead  some  time,  the 
placenta  may  be  almost 
w^hite  in  appearance,  soft 
and  greasy  in  feel.  If  the 
child  is  expelled  alive  at 
term,  the  placenta  is  often 
unusually  large  and  of  a 
pinkish  color,  due  to  the 
thickened  decidua,  which 
prevents  the  true  color  of 
the  organ  from  appearing. 
There  may  be  organized 
clots,  showing  a  previous 
hemorrhage  into  the  pla- 
centa or  the  occurrence  of 
thrombosis  in  the  lacunae; 
or  there  may  be  nodes  ^  of 
varying  extent,  lamellated 
in  structure  and  undergo- 
ing degenerative   changes 

in  the  central  portions.  Frequently  there  is  extensive  calcareous 
degeneration. 

The  consequence  of  syphilitic  disease  of  the  placenta  is 
usually  disastrous  to  the  fetus  and  often  dangerous  to  the  mother. 
The  cellular  infiltration  of  the  villi  obliterates  the  blood-vessels 
within  them,  and  consequently  abrogates  their  functions.  The 
5ame  effect  may  be  produced  by  the  hyperplasia  of  the  decidua 
serotina  and  the  consequent  encroachment  of  the  decidual  tissue 
upon  the  intervillous  blood-spaces,  or  the  destruction  of  the  villi 
may  be  brought  about  by  the  formation  of  the  nodular  masses 
that  have  been  noticed.     The  endometritis  placentaris  that  is  often 

1 "  Inaug.  Diss.,"  St.  Petersburg,  1904. 

2"Archiv  di  Ostet.  e  Gin.,"  No.  13,  1906;  "La  Ginecologia,"  No.  3,  1906; 
-"Muench.  med.  Wochenschr.,"  No.  47,  1906;  "Ann.  de  Ciyn.  et  d'01)stet.,"'  Feb.. 
1906;  "  Le  Progres  Med.,"  p.  86,  1906. 

■'Ziller,  "  Studien  iiber  Erkrankungen  der  Placenta,"  etc.,  Tubingen,  1885. 

9 


Fig.    91. — Syphilitic    disease   of    the  placenta, 
showing  Frankei's  disease. 


130  mEGNANCY. 

a  prominent  feature  of  placental  syphilis  may  prove  dangerous 
to  the  mother  by  matting  the  layers  of  the  decidua  serotina  to- 
gether, thus  subjecting  the  woman  to  the  perils  of  hemorrhage, 
septicemia,  or  inversion  of  the  uterus  that  are  incidental  to  adher- 
ent placentae. 

Tuberculosis  of  the  Placenta, — From  an  examination  of  26 
specimens  Schmorl  ^  declares  that  aU  the  component  parts  of  the 
placenta  may  be  infected  at  any  stage  of  pregnancy  and  in  any 
grade  of  the  maternal  disease. 

Placental  Hemorrhages. — The  term  placental  hemorrhage  is 
used  to  indicate  circumscribed  collections  of  blood  that  have 
undergone  more  or  less  change.  The  blood  may  be  found  as  a 
fresh  clot,  sometimes  occup3dng  a  large  area,  especially  when 
abortion  follows  the  premature  detachment  of  the  placenta;  the 
extravasated  blood  may  be  encapsulated,  surrounded  by  a  fibrous 
wall  of  varying  thickness-,  within  which  is  a  reddish  or  a  broAvnish 
fluid  ;  the  cyst  may  contain  nothing  but  clear  serum,  while  the 
coloring-matter  of  the  blood  is  deposited  upon  the  cyst-wall  or 
upon  the  surrounding  villi.  ^  The  encysted  hematocele  may  con- 
tain large  numbers  of  white  blood-corpuscles  undergoing  fatty 
degeneration,  giving  rise  to  a  liquid  resembhng  pus.  Such  cases 
have  been  described  as  abscesses  of  the  placenta. 

The  fibrin  may  predominate,  as  in  the  cases  of  throm- 
bosis of  the  placental  sinuses  described  by  Bustamente^  and 
Slavjansky,*  in  which,  if  the  clot  is  slowly  formed,  the  re- 
sulting mass  consists  of  laminated  fibrin,  as  in  aneurysms 
undergoing  obliteration.  In  other  cases  the  serum  is  rap- 
idly absorbed,  and  there  is  left  a  mass  of  red  globules  con- 
taining white  corpuscles,  either  heaped  together  or  scattered 
through  the  mass.  Finally,  the  clot  may  organize,  and  thus 
form  a  distinct  neoplasm  in  the  placenta.  The  placental  villi 
surrounding  the  extravasated  blood  usually  undergo  a  fibro- 
fatty  change. 

The  causes  of  placental  hemorrhage  are  manifold.  The  pre- 
disposing causes  are  pelvic  congestion  and  albuminuria  (Win- 
ter, Fehling);  the  slow-moving  blood-current  in  the  placental 
sinuses  and  the  excess  of  fibrin  in  the  blood  of  pregnant 
women,  predisposing  to  thrombosis ;  and  diseased  conditions 
of  the  placental  villi.  The  determining  cause  may  be  a  sud- 
den, powerful  action  of  the  heart ;  syncope,  favoring  the  for- 
mation   of   a  thrombus;    or    external    violence.       In    the    early 

1  "  Muench.  med.  Wochenschr.,"  No.  38,  1904. 

*  Ercolani  has  described  a  case  of  "placental  melanosis"  in  which  there  was  no 
trace  of  blood-extravasation,  but  the  villi  were  infiltrated  with  pigment  granules 
("Archivde  Toe,"  1896,  p.  193). 

3  Loc.  cit.  *  "Archiv  f.  Gyn.,"  1873,  Bd.  v,  360. 


THE   PLACENTA.  I3I 

months  of  pregnancy  hemorrhage  is  most  frequently  due  to  a 
true  apoplexy,  a  rupture  of  the  delicate  new-formed  blood-vessels 
in  the  decidua.  Later,  it  is  more  frequently  thrombosis  in  the 
sinuses,  or  the  laceration  of  the  delicate  blood-vessels  that  perfor- 
ate the  upper  layer  of  the  decidua  serotina  to  enter  the  placental 
sinuses.^ 

The  consequence  of  placental  hemorrhage  to  the  fetus  de- 
pends upon  the  amount  of  blood  extravasated.  Should  the 
quantity  be  large,  either  the  number  of  villi  strangulated  by  the 
clot  is  so  great  that  the  fetus  is  at  once  asphyxiated,  or  else  the 
escaping  blood  is  able,  especially  in  the  earlier  months,  to  strip 
the  placenta  off  from  the  uterine  wall,  with  the  same  result.  The 
effect  of  placental  hemorrhage  upon  the  mother  is  usually  unno- 
ticeable,  except  in  case  the  fetus  is  killed,  when  the  whole  ovum 
may  be  prematurely  expelled.  In  some  instances,  however,  the 
blood  forces  itself  between  the  placenta  and  uterus,  and,  bur- 
rowing its  way  downward  through  the  layers  of  the  deciduse, 
makes  its  appearance  externally  as  a  hemorrhage  from  the 
uterus.  Or  else  the  blood,  unable  to  escape,  collects  at  the 
placental  site,  or  possibly  over  a  large  area,  sometimes  in  such 
quantities  as  to  form  distinctly  an  additional  tumor  of  the  uterus 
appreciable  through  the  abdominal  walls,  and  also  to  give  rise  to 
all  the  symptoms  of  internal  hemorrhage. 

Cysts  of  the  placenta  are  not  rare.  In  the  majority  of 
cases  they  are  the  result  of  hyperplasia  of  the  cells  of  Langhans' 
layer  and  subsequent  liquefaction  of  a  secretion  from  these  cells. 
They  are  sometimes  due  to  a  circumscribed,  unusually  fluid 
myxoma.^  Jacquet  ^  has  described  small  cysts  springing  from  the 
blood-vessel  walls. 

Tumors  of  the  Placenta. — The  tumors  of  the  placenta  formed 
in  the  fibromyxomatous  degeneration  of  the  villi  have  already 
been  noticed.  Organized  blood-clots  have  also  been  described 
as  tumors  of  the  placenta.  Hecker^  speaks  of  a  fleshy  sub- 
stance expelled  from  the  uterus  post-partum,  although  the  pla- 
centa had  come  away  entire,  as  possibly  a  placental  tumor.  This 
may,  however,  have  been  nothing  but  a  uterine  polypus  or  a 
piece  of  hypertrophied  and  angiomatous  serotina.  ^ 

Malignant  growths  at  the  placental  site  have  long  been  recog- 

1  My  friend  Dr.  Robert  H.  Hamill,  of  Philadelphia,  has  shown  me  a  specimen 
exhibiting  an  interesting  variety  of  placental  hemorrhage.  Immediately  beneath 
the  amnion  there  was  a  large  clot  occupying  more  than  half  the  area  of  the'  placenta, 
and  evidently  containing  all  the  blood  of  the  fetal  body.  The  fetus,  corresponding 
in  development  to  the  fourth  month,  had  bled  to  death  into  its  own  placenta  from  the 
rupture  of  a  large  branch  of  the  umbilical  vein. 

2  "Archivf.  Gyn.,"  Bd.  xi,  S.  397. 

3  "Gaz.  med.  de  Paris,"  Oct.  14,  1871.  4  "Klinik  der  Geburtsh.,"  1864. 
5  See  paper  by  the  writer  in  "Am.  Jour.  Obstetrics,"  Dec,  1887. 


132 


PREGNANCY. 


nized  under  the  name  of  malignant  placental  polyps.  In  ii 
Sanger  described  a  sarcoma  of  the  decidua  serotina.  His  article 
attracted  great  attention  and  was  immediately  recognized  as  most 
important  both  in  the  nature  of  the  tumor  described  and  in  its 
histology.  The  attention  of  physicians  all  the  world  over  being 
directed  to  the  matter,  malignant  tumors  of  the  placental  site 
were  found  to  be  rather  common.  The  author  saw  five  in  as 
many  years.  In  2700  autopsies  in  the  Vienna  General  Hospital, 
from  February,  1901,  to  August,  1902,  seven  cases  were  discov- 
ered.    It  was  soon  realized,  however,  that  the  majority  of  the 


Fig.  g2. — Syncytial  cancer:  Masses  of  fibrin,^,  co  caining  islands  of  proliferated 

syncytial  cells. 

growths  observed  were  carcinoma  and     ot  sarco.na,  and  a  close 
study  of  their  histology  demonstrated  the  fact  th.  --^^er  has  , 

its  origin  in  the  syncytial  cells  of  the  chorion  vill  .xi  the 

metastases  the  syncytium  of  the  placenta  is  every  produced. 

From  recent  sections  of  the  original  tumor  studied  bv  '  "  --''■ 
it   appears  that  it  really  was  a  sarcoma.     It   is  ^' 
that  both  sarcoma  and  carcinoma  may  develop  <A 

site,  the  former  from  the  decidual  cells  (deciduo-sarc  adu- 

oma  malignum),  the  latter  from   'he   syncytium  .o-epithe- 

lioma,  carcinoma  syncytiale,  syncytial  cancer,  sync.>  uoma  m.alig- 
'    m).     Cancer  of  the  placental  site  is  vastly  more  comm-   .  than 


THE   PLACENTA. 


133 


sarcoma.  Gaylord  has  collected  55  reported  cases;  Veit,^  89; 
Teacher,^  189;  and  Briquel,^  254.  Both  of  these  malignant 
growths  have  a  rapid  course,  ending  fatally  in  from  three  to  six 
months.  Metastases  are  numerous  and  occur  early.  A  meta- 
static growth  of  syncytial  cancer  is  possible  without  a  trace  of  the 
original  tumor.     SchmorP  reports  a  syncytial  cancer  of  the  vagina 


Fig.  93. — Chorio-epithf 


of  the  vagina  without  involvement  of  the  rest  of  the 
genital  tract  (Hiibl). 


with  numerous  meta...ases,  the  uterus  being  healthy.  It  is  sup- 
posed that  t.  -jriginal  growth  is  removed  with  the  exfoliation  of 
the  decidua  serotina,  or  that  there  is  metastasis  of  chorion  villi, 
followed  by  malignant  degeneration  of  their  epithelium.^ 

1  "Tr.  of  ^       Section  on  Gyn.,"  College  of  Physicians  of  Philadelphia,  1S98. 

^"Journ.  of  Obstet.  and  Gyn.  of  the  Brit.  Empire,"  August,  1903. 

3  "  Tumeu'-.'^  du  Placenta  et  Tuneurs  Placentaires,"  p.  620,  Paris,  1903. 

*  "Centr       1.  f.  Gyn.,"  1896 

5  Zagorjanski- Kissel  has  collected  17  cases;  loc.  cit. 


PREGNANCY. 


Pig.  54 . — A  chorio-epithelioma,  from  which  the  exuberant  growth  had  been  com- 
pletely removed  by  a  ciu'ettage  the  day  before  the  panhysterectomy. 


Fig.  95. — Neoplasm  of  the  endometrium,  opposite  the  placental  site,  diagnosti 
Gated  as  chorio-epithelioma,  but  consisting  of  leukocyte  and  small  round-cell  infiltra 
tion,  possibly  a  barrier  against  syncytial  invasion  of  the  myometrium. 

Stoeckel,  Runge  and  Jaffe,  and  Pick'  have  demonstrated 
an  invariable  association  with  chorio-epitheHoma,  in  all  the  cases 

1  "Centralbl.  f.  Gyn.,"  No.  34,  1903;  see  also  Krebs,  <' Centralbl.  f.  Gyn.," 
Oct.  31,  1903,  No.  44;  "Arch.  f.  Gyn.,"  Bd.  Ixxi,  H.  3. 


PLATE   4. 


Cliorio-epitlielioma :  Rcmiived  \>y  pan-hysterectomy  cluriiii^  piRTjJcral  coiiva- 
lescoiice  from  a  premature  (k-livery.  Patient  without  recurrence  a  year  after  tlie 
operation. 


THE   PLACENTA. 


135 


they  examined,  of  an  over-production  of  lutein  and  frequently  of 
multiple  corpus  luteum  cysts  and  an  infiltration  of  the  ovarian 
stroma  by  lutein  cells. 

The  association  of  hydatidiform  mole  and  chorio-epithelioma 
is  intimate.  Briquel  found  that  in  45.5  per  cent,  of  217  cases  the 
degeneration  of  the  villi  had  preceded  the  cancer. 

Symptoms  and  treatment:  Profuse  uterine  bleedings  with  a 
foul-smelling  discharge  weeks,  months,  and  even  years  ^  after  an 
abortion  or  delivery  at  term  should  arouse  suspicion  of  a  malignant 
growth.  If  friable  neoplastic  masses  of  a  dark  purple  color  are 
removed,  and  recur  with  the  original  symptoms  in  a  few  weeks, 
the  suspicion  is  strengthened.  A  microscopic  examination  of 
the  material  removed  may  make  the  diagnosis  certain,  but  the 
penetration  of   the  myo- 

"'"-,  y. 


metrium  by  syncytial 
cells,  always  observed  in 
pregnancy  and  exagger- 
ated in  cases  of  retained 
fragments  of  placenta  or 
other  diseases  of  the  en- 
dometrium, must  be  re- 
membered. Metastases 
are  often  observed  in  the 
vagina.  The  uterus  is 
large  and  soft,  the  os  pat- 
ulous. Chorio  -  epithe  - 
lioma  has  been  demon- 
strated in  dermoids  of 
both  the  ovary  and  testi- 
cle, in  a  young  virgin  and 
in  the  brain  of  a  man, 
derived   from   a  tropho- 

blast  developed  in  the  course  of  a  dermoid  growth.^  Schmorl  and 
Hiibl  report  metastatic  growths  in  the  vagina,  the  uterus  being 
healthy.  Either  exfoliation  of  the  original  growth  occurred  or 
there  was  a  deportation  of  chorion  villi  with  subsequent  malig- 
nant degeneration. 

A  striking  peculiarity  of  chorio-epithelioma,  differentiating 
it  from  all  other  malignant  growths,  is  the  occasional  disappearance 
of  metastases  after  the  removal  of  the  original  tumor.  This 
remarkable  fact  is  best  explained  by  the  theory  that  the  organism 
produces  an  antibody   (syncytiolysin)   to  antagonize  the  hyper- 

1  Veit  mentions  cases  occurring  two,  three  and  one-half,  ami   three  and  three- 
fourth  years  after  delivery.     "  Handbuch  der  Ciynak.,"  iii,  2,  ji.  5S5. 
^Zabinsky,  "  Zentralbl.  f.  Gyn.,"  No.  18,  1904. 


Fig.  96. — Metastasis  of  syncytial  cancer  in 
liver,  showing  cells  from  Langhans'  layer  and 
true  syncytial  cells. 


1 36  PRE  GNANC  V. 

plasia  of  the  syncytium;  that  this  antibody  may  be  overwhelmed 
by  the  exuberant  growth  of  the  syncytium,  but  that  if  the  original 
and  largest  mass  of  proliferating  syncytium  is  removed,  the  normal 
balance  between  syncytiolysin  and  syncytium  is  restored,  resulting 
eventually  in  the  destruction  of  the  metastatic  growths.^ 

The  treatment  is  a  hysterectomy  at  the  earliest  possible  mo- 
ment after  making  the  diagnosis.  Veit  has  collected  29  success- 
ful operations  out  of  89  cases.  Teacher's  statistics  give  63.6 
recoveries  in  99  cases. 

Other  tumors  of  the  placenta  are  myxomata  fibrosa,  localized 
hypertrophies,  angiomata,^  and  organized  thromboses.  Bode  and 
SchmorP  report  as  a  tumor  of  the  placenta  (fibroma)  a  fibrous  de- 
generation of  a  placenta  succenturiata.  They  have  collected  the 
reports  of  thirty  placental  tumors.  Albert  {loc.  cit.)  adds  six  cases 
to  their  list.  Placental  polyps  developing  at  the  placental  site  after 
labor  are  due  to  a  sort  of  stalactitic  deposit  of  blood-fibrin  on  a  mass 
of  decidua  or  a  fragment  of  placenta.  Localized  tumors  in  the 
placenta  are  rare.  Leopold  in  more  than  7000  specimens  found 
such  a  tumor  only  once.* 

THE  UMBILICAL  CORD  OR  FUNIS. 

The  early  development  of  the  umbilical  cord,  or  the  formation 
of  the  allantois,  has  been  studied  upon  the  lower  animals,  as  in 
all  the  human  embryos  observed  the  connection  between  the 
embryo  and  the  chorion  was  already  established.  Indeed,  accord- 
ing to  His,  the  human  embryo  is  from  the  first  in  connection  with 
the  periphery  of  the  ovum.  Very  early,  therefore,  in  embryonal 
life  there  may  be  observed  a  sac-like  projection  from  the  posterior 
end  of  the  intestinal  tract,  which,  at  first  solid,  but  later  contain- 
ing a  canal,  grows  outward  and  backward,  owing  to  the  presence 
of  the  large  umbilical  vesicle  anteriorly,  until  it  comes  in  contact 
with  the  periphery  of  the  ovum.  Within  this  sausage-shaped  ^ 
projection  are  blood-vessels,  which  are  carried  with  its  growth 
to  the  periphery  of  the  ovum,  where  they  enter  the  villi  of  the 
chorion  in  the  manner  already  described.  Reduced  to  two 
arteries  and  a  vein  within  the  allantois  itself,  they  constitute 
the  vessels  of  the  umbilical  cord,  which  are  destined  to  carry 
the  blood  of  the  fetus  to  the  placenta  for  aeration  and  nutrition, 
the    two    arteries    conveying    dark,     venous    blood;    the    vein 

iSee  Hegar's  "  Beitrage,"  vol.  viii. 

'■'Albert,  "  Archiv  f.  Gyn.,"  Bd.  Ivi,  H.  I,  p.  144;  C.  Finzi,  "  Aichivio  di 
Ostet.  e  Gin.,"  No.  9,  1904. 

»"  Archiv  f.  Gyn,,"  Bd.  Ivi,  H.  i,  p.  73. 

*  V.  Mars,  "  Monatschr.  f.  Geburtsh.  u.  Gyn.,"  Bd.  iv,  H.  3,  p.  229. 

5  '  ATOih.Q,  a  sausage. 


THE    UMBILICAL    CORD. 


137 


returning  bright,  oxygenated  blood,  resembling  in  this  respect 
the  pulmonary  arteries  and  vein.  Surrounding  the  blood- 
vessels of  the  cord  is  a  peculiar  gelatinous  substance,  furnishing 


Fig-  97- — ^>  Umbilical  arteries  forming  spirals  (i,  i)  around  the  vein  ;  con- 
strictions indicating  the  presence  of  folds  {d,  e) ;  circular  folds  {d,  e) ;  lateral 
openings  showing  the  arterial  walls  ;  B,  vein  opened  upon  the  side  showing  a  con- 
striction {b)  corresponding  to  an  interior  valve  {e)  ;  semilunar  valves  (<;-,  d,  e) ; 
C,  section  of  vein  and  arteries  showing  valve  of  vein  [a),  a  semilunar  arterial  valve 
{b),  and  a  circular  arterial  valve  {c)  (Tarnier  et  Chantreuil). 

the  vessels  the  most  perfect  protection  possible  under  the  cir- 
cumstances (the  so-called  gelatin  of  Wharton),  derived  from 
the  outer  layers  of  the  amnion  and  the  allantois,  both  in  their 
turn  being  derived  from  the  median  layer  of  the  blastodermic 
membrane.  As  the  amniotic  cavity  is  distended  the  amnion 
is  pushed  out  on  all  sides  until  it  meets  in  front  of  the  em- 
bryo, and  surrounds  the  cord  like  the  linger  of  a  glove,  at  the 
same  time  inclosing  the  already  atrophied  umbilical  vesicle,  the 


Fig.  98. — A,  Section  of  the  navel:  C,  Outer  covering  with  blood-vessels;  v.u., 
umbilical  vein  ;  a.u.,  a.u.,  umbilical  artery  ;  v.o.,  omphalic  duct ;  «.,  remnant  of  the 
urachus.     B,  Section  of  the  cord  :  iV.S.,  Sheath  of  the  cord.    Other  lettering  as  in  A. 

ductus  omphalicus,  and  the  pedicle  of  the  allantois.      That  por- 
tion of  the  allantois  that  remains  within   the  abdominal  cavity  of 


138 


PREGNANCY. 


Fig.  99- — Cross-section  of  an  um- 
bilical cord  at  term,  magnified  about 
twelve  diameters :  Y,  Remnant  of  the 
allantois  ;  V,  umbilical  vein ;  A,  A, 
umbilical  arteries  (from  Minot). 


the  fetus  forms  the  bladder  and  urachus.     The  umbilical  cord  at 
term  measures  about  50.8  cm.  (20  in.)  in  length  and  about  0.9  to 

1.3  cm.  (^  to  ^  in.)  or  more  in 
diameter,  the  latter  measurement 
being  irregular,  from  the  fact  that 
the  arteries  are  coiled  around  the 
vein,  usually  from  right  to  left, 
giving  a  twisted  appearance  to 
the  cord,  and  also  because  the. 
gelatin  of  Wharton  is  deposited 
irregularly,  being  in  some  places 
quite  thick,  and  forming  thus  the 
so-called  false  knots  of  the  cord. 
Both  the  arteries  and  the 
veins  of  the  cord  have  walls  of 
almost  the  same  thickness,  and 
both  are  provided  with  semi- 
lunar and  circular  valves.  The 
caliber  of  the  vein  is  greater  than  that  of  the  arteries.  According 
to  Leopold/  it  measures  normally  2  to  4  mm.  (0.079  ^^  0.157  ^^O 
in  diameter,  but  at  a  point  about  8  to  10  cm.  (3.15  to  3.94  in.)  from 
the  placental  insertion  there  occurs  a  physiological  narrowing. 

Anomalies  of  the  Cord. — The  cord  may  be  abnormally 
long,  measuring  rarely  as  much  as  70  inches  (178  cm.),^  or  it 
may  be  naturally  or  artificially  too  short ;  and  it  may  be  absent 
altogether.  The  cord  is  artificially  shortened  in  adhesive  in- 
flammations of  the  amnion  which  result  in  the  agglutination 
of  the  coils  or  in  their  attachment  to  the  fetal  skin  or  amnion. 

Exaggerated  Torsion. — The  cord  maybe  so  twisted  upon  its 
longitudinal  axis  that  the  vessels  are  nearly  or  quite  obliterated, 
and  the  cord  itself^  especially  near  the  umbilicus,  is  reduced  to  a 
very  small  diameter.  Formerly  the  torsion  was  regarded  as  a 
cause  of  fetal  death,  but  Martin,  Ruge,  Schauta,  and  most  modern 
observers  regard  the  exaggerated  torsion  of  the  umbilical  cord 
as  a  postmortem  occurrence,  resulting  from  the  great  mobility 
within  the  uterine  cavity  of  a  fetus  that  has  died  from  the  fifth 
to  the  seventh  month  of  pregnancy.  The  number  of  twists  in 
the  cord  may  be  surprisingly  great.  In  Schauta's  ^  case  it  reached 
380.  Torsion  occurs  more  frequently  in  male  than  in  female 
children.  Edema  and  cystic  degeneration  of  the  cord  may  often 
be  found  in  connection  with  exaggerated  torsion. 

1  "Archiv  f.  Gyn.,"  Bd.  viii,  S.  221. 

*  Chantreuil,  "Disposition  de  Cordon,"  Paris,  1S75.  I  ^i^^'^  seen  one  cord  48 
and  another  56  inches  long.  The  latter  was  coiled  twice  around  the  neck  and  once 
around  the  trunk. 

^  Leopold,  "Archiv  f.  Gyn.,"  Bd.  xvii,  S.  20;  see  also  Winckel,  "  Berichte  u. 
Studien." 


THE    UMBILICAL    CORD. 


139 


Stenosis  of  the  Umbilical  Vessels. — The  umbilical  vein  may- 
be narrowed  by  the  development  in  the  intima  of  new  connective 
tissue  ^  to  such  an  extent  as  to  seriously  impede  the  flow  of  blood 
from  the  placenta, — a  condition  resulting  in  edema  of  the  latter 
organ  (hydramnios),  or  an  immense  dilatation — to  1 5  mm. 
(0.6  in.) — of  the  undiseased  portion  of  the  vein,  ending  occa- 
sionally in  its  rupture  (Leopold)  and  the  extravasation  of  blood 
into  the  substance  of  the  cord.  This  disease  of  the  vein  is 
usually  attributed  to  syphilis.  A  periphlebitis  may  also  occur, 
and  may  diminish  somewhat,  but  not  seriously,  the  caliber  of 
the  vein.  The  umbilical  arteries  are  occasionally  obstructed  by 
atheroma  and  thrombosis. 


w 


Fig.  100. — Torsion  of  the  cord. 


Fig.    lOl. — Distention    of    the     umbilical 
vessels.      Varices  of  the  cord. 


The  section  of  an  umbilical  cord  taken  from  a  syphilitic  in- 
fant sometimes  shows  an  enormous  development  of  connective 
tissue  throughout  the  entire  wall  of  the  arteries,  so  that  it  is 
impossible  to  distinguish  the  different  coats  ;  the  lumen  of  the 
vessels  is  often  obliterated,  not  only  by  the  thickened  walls,  but 
by  the  infiltration  of  the  whole  substance  of  the  cord  with  granu- 
lation cells.     Pinard "  has  seen  the  vessels  of  the  cord  obstructed 

1  "  Neue  Zeitschr.  f.  Geb.,"  Bd.  iv,  S.  62  ;  and  Leopold,  loc.  cit. 

2  "  Diet,  encyclop^d.  des  So.  ni6d.,  art.  "  Fetus." 


I40 


PREGNANCY. 


by  an  overdevelopment  of  the  valves  that  are  found  in  both 
arteries  and  veins. 

Varices  and  Rupture  of  the  Vessels  in  the  Cord — Figure 
loi  represents  a  varicose  condition  of  the  vein  of  the  cord  which 
predisposes  to  rupture.  Five  cases  of  this  accident  have  been 
collected  by  Albert.^ 

True  Knots  of  the  Umbilical  Cord. — Rarely  he  fetus  slips 
through  a  loop  of  the  cord,  and,  the  two  ends  of  the  loop  being 
then  put  upon  the  stretch,  a  true  knot  is  tied.  This  process  may 
be  repeated  either  during  pregnancy  or  while  the  child  is  descend- 
ing in  labor,  and  thus  a  double  knot  is  tied.  In  the  cord  of  an 
infant  born  under  my  care  there  Avas  a  true  figure-of-8  knot 
tied  (Fig.  102).  In  the  case  of  twins  in  a  common  amniotic 
cavity  the  most  complicated  knotting  of  the  two  cords  may 
occur.  The  effect  of  these  knots  in  the  cord  upon  the  circu- 
lation of  the  fetus  is  usually  not   serious.     Carl  Braun  ^   says 


^^^^^^^^^^^K^^i^v'-^ 

1 

l^^l 

w 

■l 

^■»^BI 

5 

1 

I1 

r^^% 

jr  ^^B 

Hh 

^x.                                   ^^ 

W^M 

l^vj 

y& 

1 

0 

Fig.   102. — A  false  and  a  true  knot  in  the  cord  (author's  cases). 

that  he  has  never  seen  the  slightest  disadvantage  to  the  fetus  from 
this  cause  ;  but  the  knots  can  be  drawn  so  tight  as  to  completely 
shut  off  the  placental  blood-supply,  especially  in  the  case  of 
twins  in  a  single  amniotic  cavity,  where  one  cord  may  be  drawn 
in  a  tight  knot  about  the  other,  obliterating  the  latter's  blood- 
vessels. The  gelatin  of  the  cord  is  often  displaced  at  the  seat  of 
the  knot,  so  that  when  the  latter  is  untied  its  situation  is  marked 
by  deep  depressions.  "  False  knots  "  of  the  cord  are  localized 
collections  of  the  mucous  tissue  in  it.  A  loop  of  the  cord  may 
adhere  by  its  proximal  edges,  giving  rise  to   a  lateral  projection 

1  "Archiv  f.  Gyn.,"  Bd.  Ivi,  H.  I,  p.  136. 
*  "  Lehrbuch  der  Ges.  Gynak.,"  p.  552. 


THE    UMBILICAL    CORD. 


141 


such  as  is  shown  in  figure  102,  in  which  there  is  a  loop  of  the 
three  blood-vessels. 

Coiling  of  the  Cord  Around  the  Fetus. — Loops  of  the  cord 
may  be  wound  about  different  portions  of  the  fetal  body.     The 


Fig.    103. — Entanglement  of 
cords  in  twins  (Winckel). 


Fig.  104. — Velamentous  insertion  of 
cord. 


neck  may  be  encircled  once  or  twice,  more  rarely  from  four  to 
nine  times  (Braun),  or  loops  may  be  thrown  around  the  limbs. 
The  encircled  part  may  be  so  compressed  that  it  is  strangulated 
and  the  distal  portion  is  destroyed,  but  it  is  doubtful  whether  a 
constricting  cord  can  ever  determine  the  amputation  of  a  part ; 
for  when  it  sinks  through  the  soft  tissues  to  the  bones  it  experiences 
a  pressure  greater  than  it  can  exert,  and  is,  therefore,  in  its  turn, 
destroyed.  Thus  the  neck  has  been  severed  to  the  spinal  column, 
and  limbs  have  been  cut  through  to  the  bone,  but  there  the  process 
usually  stops. 

Marginal  and  Velamentous  Insertion  of  the  Cord. — The 
cord  is  usually  inserted  somewhere  near  the  center  of  the  pla- 
centa. As  the  insertion  approaches  the  edge  of  that  organ,  the 
condition  receives  the  name  of  marginal  insertion,  or  battledore 
placenta.  If  the  cord  should  first  enter  the  membranes  at  some 
little  distance  from  the  placenta,  to  and  from  which  the  vessels, 
unprotected  and  more  or  less  separated  from  one  another,  pursue 
their  course  between  the  amnion  and  chorion,  a  condition  known 
as  insertio  velamentosa  exists.  The  exi)lanation  of  such  an  oc- 
currence is  obvious  :  The  allantois  is  conveyed  at  first  indiffer- 
ently to   any  portion  of  the   periphen,'  of  the   ovum,  but  as   the 


142 


PREGNANCY. 


placenta  begins  to  be  differentiated  the  embryo,  by  a  movement 
of  rotation,  enables  the  umbilical  vessels  to  pursue  a  straight 
course  toward  their  insertion  in  the  placenta.  Should  the  rota- 
tion of  the  fetus  be  in  any  way  interfered  with,  or  should  the 
newly  formed  umbilical  cord  contract  adhesions  with  the  amnion 


Fig.  105. —  Tumor  of  the  cord  :  c,  c,  c.  Cord  ;   7',  tumor;  a, a,  arteries  ;  v,  vein  (Budin). 

or  chorion  that  would  prevent  the  vessels  following  or  comply- 
ing with  the  rotation  of  the  embryo,  they  would  naturally  enter 
the  membranes  opposite  the  abdominal  face  of  the  embryo,  or  at 
that  point  where  adhesions  arrested  their  movements.  The  blood- 
vessels thus  exposed  are  liable  to  laceration  during  labor,  usu- 
ally with  a  fatal  result  to  the  fetus  unless  delivery  is  quickly 
effected. 

Umbilical  Hernia.  —  Occasionally  children  are  born  with 
some  portion  of  the  abdominal  contents  protruding  into  the 
umbilical  cord  and  covered  by  nothing  but  the  distended  and 
attenuated  amnion.  There  has  been  an  arrest  of  development  in 
the  abdominal  walls,  preventing  the  completion  of  the  arching- 
over  process  by  which  the  abdominal  cavity  is  closed. 

Cysts  of  the  Cord. — Cystic  formations  in  the  cord  are  due 
either  to  an  abnormally  fluid  condition  of  the  mucous  tissue  or 
else  to  a  collection  of  serum  in  the  pedicle  of  the  allantois,  which 
in  horses,  swine,  and  cows  is  found  persisting  as  a  vesicle  up  to 
the  time  of  birth. 

Calcareous  degeneration  is  usually  associated  with  syphilis. 
The  lime  may  be  deposited  in  the  walls  of  blood-vessels  or  in  the 
substance  of  the  cord. 


THE   DECIDU^E. 


143 


Tumors  of  the  Cord. — Tumors  of  the  cord  may  be  cysts, 
localized  hypertrophies,  or  accumulations  of  the  mucous  tissue, 
hematomata,  a  small  fetus  amorphus,  as  in  Budin's  case^  (Fig. 
105),  and  telangiectatic  myxosarcomata.  The  last  named  should 
be  excised  immediately  after  birth,  with  the  umbilical  ring.^ 


THE  DECIDUAE. 

The  explanation  which  John  Hunter  gave  of  the  plates  pub- 
Ushed  by  his  brother  William  ^  was,  for  a  long  time,  accepted  as 
the  true  history  of  the  development  of  the  uterine  membrane  which 


•^-~i^>'' 


Fig.   106. — Uterus,  decidua,  and  ovum,  on  the  eighth  day  of  pregnancy  (Leopold). 

envelops  the  fetus  at  term.  According  to  the  Hunterian  theory, 
the  uterus  throws  out  upon  its  inner  surface  an  inflammatory 
exudate  forming  a  closed  sac  whose  walls  stretched  across  the 
openings  of  the  tubes  and  the  os  internum  cervicis.  As  the  im- 
pregnated ovule  enters  the  uterus  from  one  of  the  tubes  it 
pushes  the  sac-wall  in  front  of  it,  but  leaves  behind  it  a  bare  surface, 
which  is  soon  covered  by  an  exudate  similar  to  the  one  at 
first  thrown  out.  That  portion  of  the  original  membrane 
which  remained  atttached  to  the  uterine  wall  Hunter  called  the 

'  "  Femmes  en  Couches  et  Nouveau  Nes,"  Paris,  1897,  p.  181. 
■^  V.  Winckel,   "  Centralbl.   f.  Gyn.,"'  1894,  p.  397,  reported  one  case  and  col- 
lected four  others. 

■'  "Anatomia  ut.  hum.  grav.  tab.  illuslr.,"  Birm.,  1774,  table  34. 


144 


PREGNANCY. 


membrana  decidua  vera  ;  that  portion  pushed  out  in  front  of  the 
ovule,  the  membrana  reflexa  ;  and  that  membrane  last  formed  be- 
hind the  ovule,  the  membrana  serotina.  These  names  have  sur- 
vived until  the  present  day,  although  modern  investigation  has 
robbed  them  of 'their  original  significance.  Costi  ^  was  the  first 
to  expose  the  fallacy  of  the  Hunterian  doctrine,  and  since  his  time 
the  investigations  of  Robin,  Friedlander,  Kundrat,  Leopold,  En- 
gelmann,  Peters,  Bryce,  Teacher,  and  others  have  enabled  us  to 
follow  the  changes  that  occur  in  the  uterine  mucous  membrane 
from  the  entrance  of  the  impregnated  ovule  into  the  uterine  cavity 
until  the  fetus,  with  its  enveloping  membranes,  is  expelled  at  term. 
By  the  time  the  fertilized  ovum  arrives  within  the  uterine  cavity  the 
lining  mucous  membrane  of  the  uterus  has  become  very  much  thick- 
ened,- owing  to  edema  and  congestion  of  the  upper  layers  and  to  hy- 
pertrophy of  the  uterine  glands.  xA.fter  the  third  week  the  develop- 
ment of  decidual  cells  begms:  large  cells  developed  from  the  connec- 
tive tissue,  in  certain  areas  pressed  close  together,  in  others  separated 
by  amorphous  tissue.  The  thickening  of  the  membrane  is  most 
marked  on  the  anterior  and  posterior  walls,  least  at  the  fundus 
and  cornua,  and  it  ceases  abruptly  above  the  cervix;  the  cervical 

endometrium  is  unchanged.^  As  a 
consequence  of  this  thickening  the 
mucous  membrane  is  thrown  into 
folds.  In  a  depression  between  two 
of  these  folds  of  membrane  or  on  the 
summit  of  one  of  them  the  o\aile  im- 
beds itself  when  it  first  enters  the 
uterine  cavity.  The  o^'ule,  being 
thus  imbedded  in  the  uterine  mu- 
cosa, is  inclosed  by  the  arching  over 
of  the  folds  of  the  membrane,  or, 
as  Leopold  *  claims,  by  their  simple 
approximation  owing  to  the  increas- 
ing thickness  of  the  mucous  mem- 
brane. Peters'  ^  famous  ovum  was 
found  imbedded  on  the  apex  of  one 
of  the  folds  of  uterine  mucous  mem- 
brane, being  implanted  in  the  com- 
pact layer  of  cells,  and  not  surrounded  completely  by  the  reflexa,- 
but  with  its  internal  pole  covered  by  clotted,  degenerated  blood 

1  "  Originie  de  la  Caduque,"  "Acad,  des  Sciences,"  Paris,  4  et  25  Juillel,  1842. 

2  Tenfold  according  to  Engelmann  ("Am.  Jour.  Obstetrics,"  May,  1875)  ;  from 
the  normal  2^  to  3  or  8  mm.  according  to  Pfannenstiel. 

■*  Volks   reports  a  case  and  quotes  three  others  in  which  there  was  a  decidua 
formation  in  the  cervix,  but  it  is  most  exceptional.      "Arch.  f.  Gyn.,"  Bd.  Ixix. 
*  "Archiv  f.  Gyn.,"  Bd.  xi,  S.  455. 
^  "  Die  Einbettung  des  menschlichen  Eies,"  Leipsic,  Wien,  1S99. 


Fig.  107, — Decidua  serotina, 
decidua  vera,  decidua  reflexa,  and 
the  ovum:  d.s.,  Decidua  serotina; 
d.v.,  d.v.,  decidua  vera;  d.r.,  de- 
cidua reflexa  ;  0,  ovum  (Schroeder). 


THE  DECIDUyE. 

pi.  cyt.         P.e.  cyl.  pl.        ".J- 


145 


I1"i!i»esg»wf  t 


t) 


'\       h 


i'ii 


">-* 


''-': -':>:> '\'- 


,2''-' 


'.'•■\iig-s---sS'';  ; 


yi.' 


Fig.  108. — Diagram  of  Teacher-Bryce  ovum.  (Magnified  about  50  diameters.) 
(T.  H.  Bryce,  Del.)  :  P.e.,  Point  of  entrance;  cyt,  cyto-troplioblast ;  pl,  plasmodi- 
trophoblast;  7i.z,  necrotic  zone  of  decidua;  »■/,  ^land  ;  cap,  capillaries;  //',  masses 
of  vacuolating  plasmodium  invading  capillaries.  The  cavity  of  the  blastocyst  is 
completely  filled  by  mesoblast,  and  imbedded  therein  are  the  amnio-embryonic  and 
entodermic  vesicles.  The  natural  proportions  of  the  several  parts  have  been  strictly 
observed  (Bryce  and  Teacherj. 


Fig.  109 The  decidua  vera  and  the  chorion 


Fig.  no. — Diagram  illustrating  relations  of  structures  of  the  human  uterus  at  the 
end  of  the  seventh  week  of  pregnancy  (modified  from  Allen  Thomson). 


Fig.    III. — Decidua  vera,  decidua  reflexa,  the  chorion  and  amnion. 
146 


THE   DECIDU^. 


H7 


and  fetal  elements.  The  ovum  of  Teacher  and  Bryce/  the  young- 
est and  smallest  yet  observed,  was  entirely  enclosed  in  its  decidual 
cavity  (Fig.  io8).  A  layer  of  the  decidua  is  therefore  pushed  out 
by  the  growth  of  the  ovum.  That  portion  of  the  uterine  mucous 
membrane  upon  which  the  ovule  rests,  usually  called  membrana 
decidua  serotina,  might  be  more  properly  termed  placental  or  basal 
decidua,  for  it  is  upon  this  spot  that  the  placenta  will  be  developed; 
that  portion  of  the  membrane  which  arches  over  the  ovule,  called 
by  Hunter  the  decidua  reflexa,  is  better  named  the  ovular  or  epi- 
chorial  decidua;  and  that  portion  of  the  mucous  membrane  that 
remains  as  at  first,  attached  to  the  uterine  wall,  the  decidua  vera 
of  Hunter,  is  more  appropriately  spoken  of  as  the  uterine  decidua. 
The  changes  that  occur  in  this  last  division  of  the  uterine  mucous 


Fig.  112. — Decidua  vera  and  decidua  reflexa. 

membrane  as  pregnancy  advances  are,  up  to  a  certain  point,  only  a 
continuation  of  the  change  already  noted.  The  large  cells  already 
referred  to,  the  decidual  cells  of  Friedlander,  multiply  with  great 
rapidity  and  constitute  a  thick  layer, — the  upper  portion,  or  com- 
pact layer,  of  the  uterine  decidua.  The  glands  which  at  first  send 
their  ducts  up  through  the  cellular  layer  of  decidua  are  at  last 
confined  entirely  to  the  deeper  portions  of  the  membrane,  consti- 
tuting, finally,  what  is  known  as  the  glandular  or  spongy  layer. 
In  its  early  stage  of  development  the  uterine  decidua  is  richly 
supplied  with  blood;  the  capillary  loops  spring  up  luxuriantly 
into  the  interglandular  spaces ;  while  deeper  down,  between  the 
glandular  layer  and  the  uterine  muscle,  may  be  found  numerous 
and    extensive   blood-sinuses.       But   when  the   ovular    decidua 

1 "  Contributions  to  the  Study  of  the  Early  Development  and  Imbedding  of  the 
Human  Ovum,"  Bryce  and  Teacher,  Glasgow,  1908. 


148 


PREGNANCY. 


comes  in  contact  with  the  uterine  decidua,  the  blood-vessels  are 
subjected  to  pressure  and  the  stage  of  atrophy  begins  in  the 
endometrium.  The  blood-vessels  disappear;  a  fatty  degeneration 
is  seen  in  the  cellular  layer  ;  no  trace  of  epithelium  remains  in  the 
superficial  layer  of  the  membrane,  although  epithelial  cells  persist 
in  the  glandular  layer ;  and,  finally,  as  labor  begins,  the  uterine 
decidua  separates  into  two  parts,  the  line  of  division  running 
through  the  glandular  layer,  or  between  the  compact  and  glan- 
dular layers,  the  latter  remaining  behind  in  the  uterus  to  furnish 
the  nucleus  of  a  new  mucous  membrane,  which  soon  after  labor 
takes  the  place  of  that  which  has  been  partly  cast  off.  The  history 
of  the  ovular  decidua  is  one  of  atrophy  almost  from  the  beginning. 
As  the  growing  ovum  pushes  out  this  portion  of  the  uterine 
mucous  membrane  upon  the  pole  of  the  sphere  directly  opposite 
the  placental  decidua,  the  epithelium  of  the  membrane  begins  to 

disappear  and  the  blood-vessels  are 
soon  obliterated,  so  that  at  the  end 
of  the  third  month,  when  the  ovular 
comes  in  contact  with  the  uterine 
decidua,  the  former  consists  of  not 
much  more  than  a  single  layer  of 
flattened  and  elongated  cells.  The 
development  of  the  placental  de- 
cidua has  been  described  with  that 
of  the  placenta. 

Diseases  of  the  Deciduae. — The 
decidual  mucous  membrane  of  the 
pregnant  uterus  may  be  the  seat  of 
many  of  the  diseases  that  attack  the 
endometrium  of  the  non-gravid 
uterus.  In  the  former  state,  how- 
ever, diseased  conditions  often  man- 
ifest themselves  in  exaggerated 
forms,  owing  to  the  enormous  hy- 
pertrophy of  the  mucous  membrane. 
Moreover,  in  consequence  of  its  re- 
lation to  the  fetus,  a  disease  of  the 
decidual  endometrium  has  more  serious  consequences  than  a  sim- 
ilar affection  of  the  non-gravid  uterus. 

Diffuse  Hyperplastic  Inflammation  of  the  Decidual  Endometrium. 
— The  cause  is  usually  a  preexisting  endometritis.  But  the  death 
of  the  embryo  or  some  disease  of  the  ovum  may  prove  irritating 
enough  to  incite  the  mucous  membrane  of  the  uterus,  previously 
healthy,  to  overgrowth.  As  the  constituent  parts  of  the  mucous 
membrane  are  more  or  less  affected,  the  manifestations  of  the 
disease  vary. 


Fig.  113. — Diagrammatic  rep- 
resentation of  a  section  through  the 
membranes:  a.  Amnion;  b,  chorion; 
c,  decidua  ;  f,  compact  layer ;  e,  line 
of  separation,  which  Friedlander  in- 
correctly put  in  the  compact  layer ; 
it  is  really  in  the  glandular  layer  ;  g, 
spongy  or  glandular  layer ;  d,  mus- 
cularis  (Friedlander). 


THE   DECIDUM.  I49 

Diffuse  hyperplasia  of  the  decidual  endometrium  is  an  exagger- 
ation of  the  hyperplasia  that  occurs  normally  in  the  early  months 
of  pregnancy.  Abortion  usually  results,  either  on  account  of  the 
hemorrhages  into  the  mucous  membrane,  separating  it  from  the 
uterine  wall,  or  owing  to  the  death  of  the  embryo,  from  which  all 
nutrition  has  been  diverted  to  supply  the  greater  needs  of  the 
rapidly  growing  decidua.  In  such  cases  the  embryo  may  be 
absorbed  and  the  deciduas  afterward  cast  off  as  an  empty  sac 
with  greatly  thickened  walls,  forming  one  variety  of  the  so-called 
fleshy  moles.  1  Or,  the  embryo  may  be  destroyed  in  conse- 
quence of  the  hemorrhages  into  the  hypertrophied  decidua,  the 
blood  bursting  its  way  through  all  the  membranes  and  occupying 
the  cavity  of  the  ovum,  as  well  as  surrounding  it  externally.^ 

If  the  hypertrophy  of  the  decidua  is  gradual,  the  fetus  may 
not  be  expelled  before  it  becomes  viable,  or  even  until  the  normal 
end  of  pregnancy.^  The  structure  of  the  hypertrophied  decidua 
is  usually  only  an  exaggeration  of  what  may  be  seen  in  the  decidua 
of  early  pregnancy.  There  is  a  great  multiplication  of  the  decidual 
cells,  some  of  which  are  elongated  and  seem  to  be  transforming 
themselves  into  connective  tissue;  the  blood-sinuses  are  much  en- 
larged in  the  deeper  portions  of  the  membrane,  and  there  is 
usually  an    abundance    of   connective   tissue. 

Polypoid  Endometritis. — The  decidua  may  display  upon  the 
uterine  surface  projections  or  excrescences  where  the  hyper- 
plastic process  seems  to  have  been  exaggerated  over  a  limited 
area.  Such  cases  have  been  described  by  Hofe^  and  Schroeder.^ 
To  the  most  advanced  type  of  this  polypoid  condition  of  the 
uterine  mucous  membrane  Virchow®  first  gave  the  name  of  endo- 
metritis decidualis  polyposa  or  tuberosa. 

Villus-like  projections  stand  out  from  the  mucous  membrane 
to  the  height  of  half  an  inch  or  more,  smooth  of  surface  and 
very  vascular.  In  the  intervals  between  the  projections  are 
the  openings  of  the  uterine  glands,  which  are  not  found  on  the 
polypoid  elevations.  The  whole  membrane  is  grcath^  thick- 
ened, owing  to  the  hypertrophy  of  the  connective-tissue  elements 
and  to  an  increase  in  the  decidual  cells,  which  contain  nuclei  of 
enormous  size.  The  connective  tissue  forms  fibrous  bands 
constricting  the  openings  of  the  glands,  as  well  as  the  blood- 
vessels in  the  diseased  membrane;    and  }'et  the  whole  decidua 

^  Schroeder,  "  Lehrbuch." 

*  Priestley,  loc.  cit.,  p.  28,  who  quotes  Clendrin,  Hegar,  and  Westmacott. 

'  I  have  seen  a  living  fetus,  delivered  at  the  sixth  month,  from  a  woman  who 
three  days  afterward  expelled  a  piece  of  decidua  I  cm.  thick  and  measuring  6  cm. 
in  diameter. 

■*  D.  I.  Marburg,  1869:    "  Ueber  Ilyperj^lasie  der  IJccidua." 

5  Op.  ciL,  p.  402.  0  "Die  Krankh.  Geschw.,"  Ikl.  ii,  S.  478. 


1^0 


PREGNANCY. 


is    exceedingly    vascular.       In    A'irchow's    case     there    was     a 
syphilitic   history,    and,    therefore,   he    ascribes    the    disease    to 


Fig.   114. — Polypoid  endometritis  :     a.  Fine  apertures  of  the  glands  ;   b,b,  larger 
apertures  of  the  glands;   c,c,  protuberances  or  polypi. 


Tt(herous  pTOJec- 
tions. 


Fig.  115. — Tuberous  subchorial  hematomata  of  the  decidua  (Walther). 

syphilis;  in  other  instances  no  cause  Avhatever  could  be  dis- 
covered, but  often  this  disease,  as  well  as  other  affections 
of    the    decidua,    dej^ends    upon    a    preexisting    chronic    endo- 


THE   DECIDU^. 


151 


metritis.  It  is  a  disease  of  young  ova,  and  frequently  the 
chorion  vilH  implanted  in  the  diseased  mucous  membrane  are 
in  a  condition  of  mucous  degeneration.^  In  all  the  cases 
hitherto  described  the  ovum  has  been  expelled  between  the 
second  and  the  fourth  months  of  pregnancy  (Schroeder).  Poly- 
poid endometritis  is  closely  simulated  by  blood  extravasations 


Fig.  116. — Tuberous  subchorial  hematomata  of  the  decidua  (autlior's  case). 


between  the  decidua  and  the  chorion,  as  shown  in  figures  115-  and 
116. 

Catarrhal  Endometritis. — A  chronic  inflammation  of  the  de- 
cidual endometrium  may  affect  chiefly  the  glands.  There  is  a 
hypersecretion  of  a  thin,  watery  mucus,  which  collects  between 
the  chorion  and  deciduae,  and  is  suddenly  expelled,  after  a  ruy)turc 
of  the  ovular  decidua,  in  the  later  months  of  pregnancy.  This 
occurrence  gives  rise  to  sudden  gushes  of  fluid  from  the  vagina, 
which  may  reach  a  pint  in  quantity.  Afterward  the  fluid  may 
dribble  away  for  a  considerable  length  of  time  without  affecting 
seriously  the  course  of  pregnancy,  or  else,  accumulating  once  more 

1  MuUer,  "  Bau  der  Molen,"  1867. 

''■  Walther,  "  Ceniralbl.  f.  Gyn.,"  1892,  y.  707. 


152  PREGNANCY. 

in  considerable  quantities,  it  may  again  be  suddenly  expelled. 
Two  or  three  repetitions  of  the  accumulation  of  fluid  and  its  sudden 
discharge  usually  excite  the  uterus  to  muscular  action,  and  termi- 
nate pregnancy.  This  affection  occurs  more  frequently  in  mul- 
tiparse  than  in  primiparae,  and  seems  to  depend  in  some  cases  upon 
hydremia.  The  mucous  discharge  is  one  of  the  forms  of  hydror- 
rhoea  gravidarum. 

Cystic  Endometritis.  —  If  there  is  a  hypersecretion  of  the 
uterine  glands,  and  the  escape  of  the  fluid  contained  in  the 
glandular  spaces  is  prevented,  a  condition  results,  found  only 
in  very  young  ova,  known  as  cystic  endometritis.  It  is  not 
improbable  that  this  condition  might  be  found  quite  constantly 
in  the  earlier  stages  of  the  chronic  hyperplastic  decidual  endo- 
metritis already  described,  the  glands  being  destroyed  and  oblit- 
erated as  the  disease  advances.  A  section  of  mucous  membrane 
affected  with  cystic  disease  presents  a  cavernous  appearance, 
due  to  numerous  small  cysts.  Their  connection  with  the 
uterine  glands  may  be  demonstrated  by  the  relation  between  the 
cysts  and  the  ducts  of  the  glands.^  About  the  cysts  the  decidua. 
is  hypertrophied,  presenting  the  overdevelopment  of  connective 
tissue,  increase  of  decidual  cells,  and  embryonal  tissue  already 
described.^ 

The  prognosis  of  all  these  chronic  affections  of  the  decidual  en- 
dometrium is  unfavorable  for  the  fetus  and  for  the  mother.  There 
is  danger  to  the  fetus  from  hemorrhages,  which  bring  about  sep- 
aration of  the  membranes,  or  which,  bursting  through  all  the 
fetal  envelopes,  overwhelm  the  embryo  with  blood  ;  there  may 
be  diversion  of  nutriment  from  the  embryo  to  the  overgrown 
decidua,  and  the  irritation  of  the  chronic  inflammation  or  of  a 
hemorrhage  may  result  in  excitation  of  muscular  action  upon 
the  part  of  the  uterus,  which,  ends  in  the  expulsion  of  the  ovum. 
The  possible  loss  of  blood  during  pregnancy,  and  the  retention 
of  fragments  of  decidua  owing  to  adhesive  inflammation  after 
the  ovum  is  expelled,  are  not  without  their  effect  upon  the 
mother. 

The  treatment  of  this  condition  during  pregnancy  is  impos- 
sible. Its  prevention  may  be  attempted,  however,  by  a  curettage 
before  impregnation  occurs  again. 

Acute  Inflammation  of  the  Deciduae. — Acute  inflammation  of 
the  decidual  membranes  may  develop  in  the  course  of  cholera 
and  other  infectious  diseases,  especially  the  exanthemata,  in 
consequence  of  unsuccessful  attempts  to  induce  abortion,  or 
as  a  result  of  traumatism. 

'  Leopold,  "  Gesellsch.  f.  Geburtsh.,"  Leipsic,  Feb.,  1878. 
^  See  Breus,   "  Ueber  cystose   Degeneration  der  Decidua  Vera,''    "  Archiv  f. 
Gyn.,"  Bd.  xix,  S.  4S3. 


THE  DECIDU.E. 


153 


Hemorrhagic  decidual  endometritis  is  the  name  given  to  the 
condition  of  the  mucous  membrane  found  in  two  cases  of 
cholera,*  and,  no  doubt,  present  in  other  grave  infectious  dis- 
eases. The  decidua  is  thickened,  of  a  dark,  purpHsh  hue,  and 
presents  throughout  its  substance  numerous  extravasations  of 
blood. 

Exanthematous  Decidual  Endometritis. —  Klotz,^  in  eleven 
cases  of  measles  in  pregnancy,  noted  in  nine  a  premature  ex- 
pulsion of  the  fetus,  the  time  at  which  the  expulsive  efforts 
began  coinciding  with  the  appearance  of  the  rash.  In  these 
cases,  according  to  Klotz,  the  uterine  action  is  excited  by  the 
occurrence  of  an  exanthema  upon  the  uterine  mucous  mem- 
brane, highly  irritating  in  its'  action,  just  as  the  photophobia, 
the  coiyza,  the  bronchitis,  and  the  vesical  tenesmus  of  measles 
indicate  an  irritated  condition  of  the  mucous  membranes  of  the 
eyes,  nose,  lungs,  and  bladder.  Salus^  in  thirteen  cases  saw 
the  same  tendency  to  miscarriage.  It  is  probable  that  this  con- 
dition of  the  uterine  mucous  membrane  accounts  for  the  abor- 
tions or  premature  labors  that  often  occur  when  pregnant  women 
are  attacked  by  any  of  the  eruptive  fevers. 

Purulent  and  Microbic  Decidual  Endometritis. — Donat  *  has  de- 
scribed a  case  of  purulent  endometritis  in  pregnancy.      A  woman 
expelled  at  term  a  placenta  about  the  periphery  of  which   could 
be  seen  masses  of  decidua  infil- 
trated with  pus.    The  amnion  and 
chorion  w^ere  both  thickened  and 
opaque,  and  between  them  was  an 
accumulation   of  purulent   fluid. 
It  was  suspected  that  the  suppur- 
ation of  the  decidua  was  the  re- 
sult of  unsuccessful  attempts  on 
the  part  of  the  woman  to  bring 
on  a  miscarriage. 

Tuberculous  endometritis^  in 
pregnant  women  has  been  re- 
ported by  several  observers.  In 
three  instances  pregnancy  went 

to  term  in  spite  of  the  caseous  degeneration  of  the  mucosa 
one  case  rupture  of  the  uterus  occurred  at  the  third  month. 

Atrophy  of  the  Deciduae. — The  deciduae,  instead  of  undergoing 
inflammatory    and    hyperplastic    changes,    may    rarely    atrophy. 

1  Slavjansky,  "Archiv  f.  Gyn.,"  Bd.  iv,  S.  285. 

2  "  Archiv  f.  Gyn.,"  Bd.  xxix,  S.  448. 

'  "  Piager  med.  Wochenschr.,"  1899,  No.  7. 

*  "Archiv  f.  Gyn.,"  Bd.  xxiv. 

5  Vineberg,  "American  Gynecology,"  October,  1903. 


Fig.    117. — Atiiiphy  of  the  decidua,  ex- 
ternal surface  of  the  vera  (Duncan). 


In 


154  PREGNANCY. 

This  process  has  been  described  by  Hegar/  Matthews  Dun- 
can,- Spiegelberg,^  and  Priestley.*  The  uterine,  ovular,  or 
placental  decidus  may  singly  or  conjointly  be  the  seat  of 
atrophy,  resulting  in  the  attachment  of  the  ovum  by  a  slender 
pedicle  to  the  uterine  wall,  or  in  its  rupture  and  the  discharge 
of  its  contents  from  the  uterus.  As  a  result  of  the  stretch- 
ing of  the  pedicle  in  cases  of  placental  atrophy,  the  ovum 
may  be  pushed  downward  by  the  uterine  contractions  until  it 
rests  in  great  part  within  the  cervical  canal.  This  condition  con- 
stitutes the  cervical  pregnancy  of  Rokitansky. 

1  "  Monatsh.  f.  Geburtsh.  u.Fr.,"  Bd.  xxi ;  Supplem.,  pp.  ii,  19,  1863. 

2  "Researches  in  Obstetrics,"  p.  295,  1868. 

3  "  Lehrbuch,"  p.  328.  '         .  ^  Op.  cit. 


THE   DISEASES   OF  THE  FETUS.  155 


CHAPTER  V. 
The  Diseases  of  the  Fetus. 

Fetal  mortality  exceeds  that  of  any  other  period  of  life.  It 
has  been  estimated  that  for  every  four  or  five  labors  there  has 
occurred  one  abortion,  and  if  to  this  number  be  added  the 
still-births  in  which  the  death  of  the  fetus  was  not  due  to  an  ac- 
cident in  labor,  the  proportion  of  fetal  deaths  to  living  births  is 
very  large.  In  addition  to  the  diseases  having  a  fatal  termination, 
there  are  others  running  their  course  wholly  or  in  part  during 
intra-uterine  life  and  ending  in  recovery;  so  that  the  list  of  fetal 
diseases  is  an  extensive  one. 

The  present  chapter  treats  of  the  diseases  of  the  fetal  or- 
ganism itself,  of  weakness  dependent  upon  defects  in  the 
paternal  elements  entering  into  the  composition  of  the  embryo, 
and  of  maternal  conditions  which  are  incompatible  with  the 
healthy  development  or  with  the  continued  existence  of  the 
product  of  conception. 

Fetal  Syphilis. — First  in  importance  of  all  the  diseases  of 
intra-uterine  life,  fetal  syphilis  deserves  extended  notice.  Ac- 
cording to  Ruge,^  eighty-three  per  cent,  of  repeated  premature 
and  still-births  have  their  cause  in  syphilis  of  one  or  both  of  the 
parents.  Of  657  pregnancies  in  syphilitic  women  collected  by 
Charpentier, 2  thirty-five  per  cent,  ended  in  abortion,  and  of  the 
children  that  went  to  term  a  large  number  were  still-born.  Of 
100  conceptions  in  syphilitic  women,  only  seven  children  were 
alive  a  year  later.  ^ 

The  syphilitic  infection  of  the  fetus  is  due  to  syphilis  in  the 
mother  or  father  before  conception  or  to  syphilitic  infection  of 
the  mother  during  pregnancy. 

Syphilis  may  be  transmitted  from  a  syphilitic  father  direct 
to  the  embryo  without  infection  of  the  mother.  As  the  fetus 
grows  and  the  syphilitic  poison  develops  with  its  growth, 
the  mother  becomes  mildly  infected  in  her  turn  dirccth'  from 
the  fetus  through  the   uteroplacental   circulation.'*      The  longer 

^  See  Lomer,  "  Zeitschr.  f.  Geburtsh.,"  Bd.  x,  p.  189. 

2  *'  Trait6  pratique  des  Accouchements." 

3  Pileur,  "Bull,  de  la  Soc.  d'Obst.  at  de  Gyn.,"  Paris.  Dec.  13,  18S8. 

■*  See  Tarnier  et  Budin,  op.  cif.;  Priestley,  loc.  cil.:  ].  Hutcliinson,  "British 
Med.  Jour.,"  Feb.,  18S6,  y,.  239;  Harvey,  "Fetus  in  Utero,"'  1SS6  ;  G.  S.  West, 
*'Am.  Jour.  Obstetrics,"  1S85,  p.  182. 


156  PREGNANCY. 

the  time  since  the  acquisition  of  the  disease  by  either  parent, 
the  less  hkeUhood  there  is  of  syphihs  in  the  embryo  ;  but  the 
Hmit  of  safety  has  not  yet  been  discovered.  According  to 
Fournier/  four  years  is  the  maximum  of  time  that  syphihs  can 
remain  latent,  but  Lomer  ^  reports  the  birth  of  a  syphilitic  infant 
ten  years  after  the  first  infection  of  the  father,  and  Kassowitz  ^ 
records  a  latent  syphilis  of  twelve  years'  duration. 

Vajda  *  and  Hutchinson  ^  describe  cases  in  which  preg- 
nant women  were  infected  near  term  and  gave  birth  to  syph- 
ilitic children.  Neumann  ^  has  published  observations  of  20 
women  who  were  infected  with  syphilis  during  pregnancy ;  5 
of  this  number  gave  birth  to  syphilitic  children,  and  of  these  5 
2  were  infected  at  the  fourth  and  i  each  at  the  third,  seventh, 
and  eighth  months.  Hirigoyen  "^  has  reported  12  cases  in  which 
the  mother  contracted  syphilis  during  the  first  four  months  of 
pregnancy  ;  all  the  children  were  still-born  ;  in  cases  of  infection 
from  the  fourth  to  the  sixth  month,  about  half  the  children  were 
still-born  ;  and  in  7  cases  of  infection  during  the  last  three  months 
of  pregnancy  there  were  4  still-births.^ 

The  manifestations  of  fetal  syphilis  are  bullous  eruptions  of 
the  skin,  condylomata,  inflammations  of  the  mucous  and  serous 
membranes,  gummatous  and  miliary  deposits,  morbid  growth  of 
connective  tissue  in  the  brain,  lungs,  pancreas,  kidneys,  liver, 
spleen,  the  muscular  system,  the  coats  of  the  intestines  and 
walls  of  the  blood-vessels,  and  a  characteristic  osteitis  and  osteo- 
chondritis. 

The  prognosis  is  unfavorable.  If  the  fetus  is  not  destroyed 
before  it  is  viable,  it  is  often  retarded  in  development,,  feeble, 
and  diseased.  There  is  an  enlarged  abdomen,  due  to  ascites,  to 
enlarged  liver  or  spleen  ;  nodes  in  the  lungs  or  in  the  bronchial 
glands  ;  hydrocephalus  ;  separation  of  the  epiphyses  of  the  long 
bones  from  the  diaphyses  ;  extensive  pemphigoid  eruptions  on 
the  skin,  or,  possibly,  the  fetus  is  deformed  or  monstrous  in 
appearance.  There  are  cases,  however,  in  which  the  course  of 
intra-uterine  life  does  not  seem  to  be  influenced  in  the  slightest 
degree  by  syphilis.  The  children  are  born  apparently  healthy 
and  well  developed,  but  exhibit  unmistakable  signs  of  their 
hereditary  taint  within  the  first  few  weeks  after  birth. 

^  "Syphilis  et  Marriage."  ^  "Zeitschr.  f.  Geburtsh.,"  Bd.  x,  94. 

*  Strieker's  "Jahrb.,"  1875,  p.  476. 

*  "Centralbl.  f.  Gyn.,"   1880,  p.  360.        ^  <«  British  Med.  Jour.,"  1886,  i,  239. 
6  "  Wien.  med.  Presse,"  29,  30,  1885. 

■^  Abstract  in  "  N.  Y.  Med.  Record,"  April  12,  18S7. 

*  The  author  has  seen  a  woman  impregnated  by  a  healthy  man,  but  infected  with 
syphilis  in  the  third  month  of  pregnancy,  give  birth  to  a  syphilitic  child. 


PLATE  5, 


Head  of  femur  removed  from  a  fetus  expelled,  dead  and  macerated,  at  the 
seventh  month.  The  liver  weighed  one-tenth  of  the  body-weight  ;  the  spleen,  one- 
forty-eighth.      The  mother  was  infected  with  syphilis  one  year  before. 


777^  DISEASES  OF  THE  FETUS.  15; 

Diagnosis  of  Fetal  Syphilis. — The  infection  of  the  fetus  may  be 
inferred  with  reasonable  certainty  if  either  parent  had  acquired 
syphihs  at  a  date  not  too  remote  from  the  procreation.  If  a 
woman  acquires  a  chancre  during  pregnancy,  the  possibihty  of 
the  disease  attacking  the  fetus  must  not  be  overlooked.  A  sign 
of  syphilis  in  the  fetus  is  occasionally  furnished  by  the  symp- 
toms of  secondary  syphilis  in  the  mother  without  a  trace  any- 
where of  a  primary  sore.  In  such  cases  the  disease  may  have  been 
transmitted  from  fetus  to  mother. 

Often  the  signs  of  fetal  syphilis  can  be  looked  for  only  in 
the  fetus  itself,  after  its  expulsion  from  the  uterus,  and  much  may 
depend  upon  a  correct  diagnosis.  The  parents'  history,  from 
ignorance  or  design,  may  be  entirely  negative.  The  child  may  be 
born  with  no  distinctive  mark  upon  its  body.  If  it  is  living,  the 
coryza  and  characteristic  eruptions  during  the  first  few  weeks 
usually  point  clearly  to  the  hereditary  taint.  If  it  has  pemphigus 
the  spirochseta  pallida  may  be  found  in  the  fluid  from  the  blebs. 
If  the  child  is  dead,  the  diagnosis  can  easily  be  made. 

If  the  practitioner  is  a  trained  pathologist,  the  detection 
of  syphilis  is  easy.  The  bullous  eruption  on  the  skin,  the  con- 
dylomata and  inflammations  of  the  mucous  membranes  and 
serous  membranes,  the  gummatous  deposits  and  the  morbid 
growth  of  connective  tissue  in  the  brain,  lungs,  pancreas,  kid- 
ney, liver,  spleen,  in  the  coats  of  the  intestines  and  walls  of  the 
blood-vessels,  and  a  characteristic  osteochondritis,  demonstrate 
the  character  of  the  disease.  The  spirochaeta  pallida  may  be 
found  in  the  fetal  tissues,  the  umbilical  cord,  and  the  placenta 
(p.  129).  The  general  practitioner  often  observes  cases  of  repeated 
fetal  death  the  cause  of  which  is  obscure,  although  suspicion  natur- 
ally rests  upon  syphilis.  Thanks  to  the  investigations  of  Weg- 
ner,^  Ruge,^  Lomer,=*  and  others,  syphilis  can  be  recognized  in  the 
fetus  by  a  few  signs  easily  found,  perfectly  reliable,  and  requiring 
for  their  detection  no  special  training  in  the  methods  of  patholog- 
ical research.  Wegner  was  the  first  to  call  attention  to  a  curious 
condition  of  the  dividing  line  between  diaphysis  and  epiphysis 
of  the  long  bones  of  a  syphilitic  infant.  Instead  of  a  sharp, 
regular,  delicate  line,  formed  by  the  immediate  apposition  of  car- 
tilage to  bone,  as  in  a  healthy  fetus,  there  is  seen  in  syphilis  a  broad 
jagged  yellow  line  *  (Plate  5).  A  microscopic  study  of  tliis  portion  of 
the  bone  shows  that  there  has  been  a  premature  attcmjjt  at  ossi- 

1  Virchow's  "  Archiv,"  Bd.  i,  S.  305. 

2  "  Zeit.  f.  Geburtsh.,"  Bd.  i.  ^  F'id.,  V>A.  x. 

4  To  discover  Wegner's  sign,  an  incision  sliould  be  made  over  the  trochanter,  as 
though  for  excision  of  the  head  of  the  femur.  The  end  of  the  thigh-bone  is  turned 
out  after  cutting  its  ligaments,  and  a  median  section  of  the  ejiiphysis  and  diaphysis 
of  the  bone  is    made  with  a  strong  cartilage-knife. 


158  PREGNANCY. 

fication,  which  has  ended  in  necrosis,  fatty  degeneration,  and 
suppuration. 

For  more  than  a  year  I  carefully  looked  for  this  sign  in  eveiy 
case  of  unmistakable  fetal  syphilis  that  occurred  in  the  Philadel- 
phia and  Maternity  Hospitals,  and  never  failed  to  find  it,  while 
in  doubtful  cases  it  proved  a  valuable  aid  to  a  correct  diagnosis. 
In  the  Frauenklinik,  at  Berlin,  ^  this  sign  was  also  carefully  inves- 
tigated, with  a  result  wholly  favorable  to  its  distinctive  character.  ^ 

According  to  Ruge,  ^  the  liver  of  a  healthy  infant  should 
constitute  about  -^  part  of  the  body-weight.  In  syphilitic 
infants  this  proportion  is  much  exceeded,  the  liver  reaching,  in 
extreme  cases,  \  of  the  total  body-weight.  The  spleen,  too, 
usually  -gi-Q-  of  the  body-weight,  is  much  enlarged  in  syphilis. 
Upon  these  three  signs, — the  yellow  line  between  epiphysis  and 
diaphysis,  the  increased  weight  of  liver,  and  increased  weight  of 
spleen, — all  easily  discovered,  the  diagnosis  of  syphilis  may  rest 
with  reasonable  certainty.  Valuable  indications  of  s}'philis  are 
also  found  in  the  lungs  ^  :  an  interstitial  overgrowth  ;  the  pres- 
ence of  gummata ;  a  peculiar  catarrhal  inflammation,  resulting  in 
what  is  called  white  pneumonia.  The  interstitial  overgrowth  is 
the  most  common.  The  newly  formed  connective  tissue  about 
the  blood-vessels  and  alveoli  gives  the  lungs  greater  weight  and 
more  solidit}^  than  usual ;  their  color  is  often  dark  red ;  if  the 
infant  has  breathed  for  a  short  time  after  birth,  the  lungs  wull  not 
float  buoyantly,  although  they  do  not  usually  sink  outright.  The 
alveoli  are  much  encroached  upon  by  the  interstitial  thickening ; 
lung-expansion  and  adequate  respiration  are  impossible.  The 
catarrhal  pneumonia  due  to  syphilis  is  rare.  The  lungs  are 
large  and  heavy;  they  completely  fill  the  thoracic  cavity  and 
bear  upon  their  external  surface  the  imprint  of  the  ribs  ;  in  color 
they  are  yellowish-white,  from  fatty  degeneration.  The  alveoli 
are  filled  with  desquamated  epithelial  cells.  This  condition  is 
incompatible  with  extrauterine  life  :   the  infant  never  breathes. 

The  treatment  of  fetal  syphilis  during  pregnancy  is  a  thorough 
course  of  antisyphilitic  treatment  in  the  mother.  If  the  fetus 
derives  its  syphilis  from  one  parent  alone,  treatment  of  the 
healthy  individual  before  impregnation  is  superfluous  ;  but  in 
case  of  doubt  it  is  wise,  in    the   preventive  treatment  of   fetal 

^  Lomer,  loc.  cit. 

2  Zweifel  thus  describes  the  progress  of  the  disease  :  "There  is  formed,  in  a  cer- 
tain region  of  the  cartilage,  granulation-tissue  insufficiently  supplied  with  blood- 
vessels and  ill-nourished.  There  results  necrosis  of  this  tissue,  with  an  attempt  at 
exfoliation  and  accompanying  suppuration." 

'  Loc.  cit. 

•t  For  an  exceedingly  interesting  paper  on  this  subject  see  Heller,  "  Die  Lung- 
enerkrankungen  bei  angeborener  Syphilis,"  "  Deutsch.  Archiv  f.  klin.  Med.,"  Bd.  xlu, 
S.  159- 


THE  DISEASES    OF   THE  FETUS.  1 59 

syphilis,  to  administer  to  both  man  and  woman  the  appropriate 
remedies. 

Should  a  pregnant  woman  come  under  the  observ^ation  of  a 
physician  with  the  history  that  she  had  had  syphilis,  that  she  was 
with  child  by  a  syphilitic  man,  although  healthy  herself,  or  that 
she  had  acquired  a  chancre  subsequent  to  conception,  she  should 
receive  mercuiy  and  iodid  of  potassium.  I  prefer  mercurial  oint- 
ment inunctions  daily,  and  about  15  gr.  (i  gm.)  of  iodid  of  po- 
tassium three  times  a  day,  after  meals,  in  milk,  during  the  whole 
duration  of  pregnancy.  Under  this  treatment  I  have  seen  women 
who  had  given  birth  to  a  succession  of  still-born  syphilitic  fetuses 
bear  living  children  perfect  in  health  and  development,  without  a 
trace  in  after  life  of  hereditary  taint. 

Other  Infectious  Diseases  of  the  Fetus. — xA.s  the  infectious 
diseases  are  dependent  upon  the  entrance  of  bacteria  into  the 
system  for  their  characteristic  symptoms,  it  is  impossible  that  they 
should  directly  affect  the  fetus  in  utcro,  unless  pathogenic  micro- 
organisms are  able  to  pass  from  the  maternal  blood  through  the 
uteroplacental  septum  into  the  fetal  portion  of  the  placenta. 

It  appears  from  experiments  extending  over  the  last  fifty  years 
with  various  bacteria  that  micro-organisms  may,  but  do  not  always, 
pass  from  mother  to  fetus.  Moreover,  there  is  a  long  list  of  dis- 
eases due  to  the  presence  of  specific  micro-organisms,  which  have 
in  well-authenticated  cases  undoubtedly  attacked  the  fetus  in  utero. 

Variola. — Many  cases  are  recorded  in  which  a  child 
marked  with  pustules  was  born  of  a  mother  who  had  had 
variola  during  pregnancy.  But  the  susceptibility  of  the  fetus  to 
the  disease  varies.  In  the  majority  of  cases  it  is  not  infected.  On 
the  contrary,  the  mother  may  have  only  varioloid  and  yet  the  child 
be  born  with  the  marks  of  small-pox  ;  ^  or  the  mother,  having 
been  exposed  to  the  contagion  of  small-pox,  but  having  shown  no 
sign  of  the  disease,  may  give  birth  to  a  child  covered  with  pus- 
tules. ^  Again,  it  has  been  noted  that,  of  twins,  one  or  both  of 
the  children  may  be  affected.^  ,The  fact  that  small-pox  can 
attack  the  fetus  has  led  many  observers  to  test  the  possibility  of 
an  intra-uterine  vaccination.  Behm  ^  vaccinated  ■^■^  women,  and 
of  their  children  25  were  successfully  vaccinated  after  birth. 
Wolff  '5  says  that  he  has  repeatedly  vaccinated  pregnant  women, 
and  has  never  failed  to  vaccinate  successfully  their  offspring. 
Ridgen''    reports    8   cases  of  small-pox    occurring  in  pregnant 

1  Charcot,  "  Comptes  rendus  de  la  Society  de  Biologic,"  1S51,  p.  39,  and  1853, 
p.  88  ;  Chaigneau,  "  Th^se  de  Paris,"  1847  ;  Chantreuil,  "  Gaz.  des  Ilopitaux,"  1870. 

2  Laurent,  "  Lyon  Medicale,"  June  15,  1884. 

*  "  Obstet.  Trans.,"  London,  vol.  iii,  p.  173. 

*  "  Zeitschr.  f.  Geburt.,"  Bd.  vii,  p.  i. 

5  Virchow's  "  Archiv,"  Bd.  cv,  p.  192. 
«  "  British  Med.  Jour.,"  1877,  i,  p.  229. 


l60  PREGNANCY. 

women,  in  whose  children,  born  alive,  a  subsequent  vaccination 
"took."  On  the  other  hand,  Desnos^  and  Chambrelent-  each 
relate  a  case  in  which  vaccination  was  several  times  unsuccess- 
fully performed  upon  children  whose  mothers  had  shortly  before 
their  delivery  recovered  from  an  attack  of  small-pox.  Chambre- 
lent, moreover,  vaccinated  7  pregnant  women,  but  of  their  chil- 
dren he  was  able  successfully  to  vaccinate  only  3.  The  fetus, 
therefore,  in  exceptional  cases  acquires  immunity  from  small-pox 
by  the  vaccination  of  its  mother. 

Measles. — The  transmission  of  measles  from  mother  to  fetus 
is  rare.  Thomas^  was  able  to  collect  6  cases  from  medical  lit- 
erature. There  are  also  recorded  cases  of  measles  appearing  in 
the  first  few  days  of  extra-uterine  life,  making  it  probable,  from 
the  short  period  of  incubation,  that  infection  had  occurred  in 
titero. 

Scarlatina. — Leale  *  reports  the  birth  of  a  boy  at  the  begin- 
ning- of  a  well-marked  attack  of  scarlet  fever  in  the  mother,  which 
she  had  contracted  from  an  older  child.  The  new-born  infant 
presented  a  dark,  congested,  red  hue  and  a  characteristic  rasp- 
berry tongue.  The  eruption  lasted  seven  days  and  desquama- 
tion began  on  the  tenth  day,  when  albuminuria  and  general 
anasarca  indicated  a  desquamative  nephritis.  The  child  recov- 
ered. Other  cases  are  recorded  by  Hiiter,  Meynet,  x\smus, 
Baillou,  Tourtual,  Gregory,  and  Stichel.  Saffin^  has  reported  an 
interesting  case  of  intra-uterine  scarlet  fever :  A  woman,  w^ho  had 
had  scarlet  fever  in  childhood,  was  nursing  her  child  through  the 
disease,  while  she  herself  was  in  the  last  month  of  pregnancy. 
She  was  apparently  not  infected,  but  complained  of  a  bad  sore 
throat.  Two  weeks  later  she  was  deli\'ered  of  a  male  child 
with  a  typical  scarlet  rash  upon  it ;  the  disease  ran  a  course  of 
nine  days,  wdth  desquamation  in  large  and  small  flakes,  begin- 
ning on  the  fifth  day.  The  infant's  temperature  ranged  from 
100°  to  104°  F.;  it  recovered. '^ 

Erysipelas.— Kaltenbach,'  Runge,^  and  Stratz »  have  re- 
ported cases  apparently  of   fetal   erysipelas.     Lebedeff  i"  reports 

1  Societe  med.  des  Hopitaux,  1871  (see  Tarnier  et  Budin,  op.  ciL,  p.  13). 

2  Loc.  cit.,  p.  385. 

^Ziemssen's  "Handbook."  vol.  ii,  p.  50  (see  also  Underbill,  '•' Obstet.  Jour., 
Great  Britain  and  Ireland,"  iSSo,  p.  285,  and  MacDonald,  '•  Edin.  Med.  Jour.," 
1884-85,  699). 

*  "Medical  News,"   1884,  p.  636. 

5  "New  York  Med.  Record,"  April  24,  1SS6. 

6  For  full  bibliography  see  Ballantyne  and  Miliigan,  "  Edinb.  ]\Ied.  Jour.," 
July,  1893. 

'  "  Centralblatt  f.  Gyn.,"  No.  44,  1S84. 

8  "  Centralblatt  f.  Gyn.,"  No.  48,  1S84.  "  ■•  Centralblatt  f.  Gyn.,''  ix,  213. 

10  "  Zeitschr.  f.  Geburt.,"  xii,  2,  p.  321. 


THE   DISEASES   OF   THE   FETUS.  l6l 

the  following  case  :  The  child  of  a  woman  delivered  at  the  sev- 
enth month  in  the  midst  of  an  attack  of  erysipelas  presented 
alternate  patches  of  red  and  white  on  its  skin  at  birth  ;  it  lived  ten 
minutes  ;  after  death  streptococci  were  found  in  the  subcutaneous 
adipose  tissue,  were  cultivated,  and  rabbits  inoculated  with  the 
cultures  acquired  the  disease.  No  microbes,  however,  Avere  found 
in  the  placenta  or  cord.  Lebedeff  believes  that  the  streptococci 
entered  the  placenta  through  a  villus  depriv-ed  of  epithelium. 

Malaria. — Behrmann  reports  two  cases  of  intra-uterine  infec- 
tion in  which  the  disease  manifested  itself  directly  after  birth. 

Malaria  in  the  mother  retards  the  growth  and  development 
of  the  fetus.  Bompiani  ^  says  that  children  born  of  malarial 
mothers  very  rarely  reach  3250  gm.  (7.17  lbs.)  in  weight  or  50 
cm.  (19.7  in.)  in  length,  and  Negri-  observed  34  cases  in  preg- 
nant women,  of  which  18  per  cent,  terminated  by  premature 
expulsion  of  the  fetus.  Quinin  in  large  doses  to  the  mother  is 
indicated.  "  Quinin  in  this  condition  is  the  best  proph}'lactic 
treatment  against  abortion  or  premature  labor"  (Tarnier). 

Economos^  has  found  the  plasmodium  in  6  out  of  7  newborn 
infants  whose  mothers  had  malaria. 

Tuberculosis. — In  view  of  the  large  number  of  tubercu- 
lous women  who  become  pregnant,  it  is  an  extraordinary  fact 
that  the  direct  transmission  of  the  disease  from  the  mother  to 
the  fetus  is  an  extremely  rare  occurrence.  Runge*  infected  a 
number  of  pregnant  guinea-pigs  with  tuberculosis, 'but  invariably 
failed  to  find  the  characteristic  bacilli  in  the  fetal  tissues  or  pla- 
centa. Ballinger,  Davaine,  Brauell,  and  Wolff  have  denied  the 
existence  of  congenital  tuberculosis,  and  Jani's  observ^ations 
have  already  been  noticed.  But  Demme  once  found  tubercle 
bacilli  in  the  macerated  fetus  of  a  tuberculous  woman,  and 
Johne"*  discovered  tubercles  in  a  still-born  calf,  in  which  he 
found  the  bacilli.*^  Runge  has  demonstrated  tubercle  bacilH  in 
the  placenta  and  in  the  maternal  decidua.  Tubercle  bacilli  have 
been  demonstrated  in  the  fetal  portion  of  the  placenta  by  Lehman, 
Schmorl,  Kockel,  Auche,  and  Chambrelent.  While,  therefore, 
there  is  a  remote  possibility  of  the  passage  of  tubercle  bacilli 
from  mother  to  fetus,  it  is  an  exceptional  occurrence.'' 

1  "Annal,  di  Obstet.,"  vi,  42,  46,  1884.  '■'  "Annal.  di  Obstet.,"  viii,  p.  277. 

•*  "  Soc.  d'Obstet.  de  Paris,"  25,  February,  1907. 

*  Quoted  by  Ott,  loc.  cit,  ^  Quoted  by  Wolff,  loc.  cil. 

6  Ravenel  reported  a  similar  case  to  the  Pliiladelpliia  Pathological  Society,  Feb. 
23,  1899. 

"^  See  A.  S.  Warthin,  "  Ectopic  Gestation  ;  Tuberculosis  of  Tubes,  Placenta,  and 
Fetus,"  "Med.  News,"  Sept.  19,  1896;  BirchTIirschfeld,  "  Beitr.  z.  path.  .Vnat.  u. 
zur  allgem.  Path.,"  1891  ;  "Archiv  f.  Gyn.,"  Bd.  xliii,  H.  i,  p.  162.  Hauser, 
"Deutsch.  Arch.  f.  klin.  Med.,"  1898,  vol.  Ixi,  p.  221,  18  cases.  Gottschalk, 
■'Arch.  f.  Gyn.,"  Bd.  Ixx,  li.   i  ;    "Arch.  f.  Gyn.,'"  Bd.  Ixviii. 


1 62  PREGNANCY. 

Septicemia. — The  possibility  of  the  transmission  of  septic 
micro-organisms  from  mother  to  fetus  has  been  denied  by  many, 
but  the  antenatal  infection  of  the  fetus  has  been  demonstrated  by 
Koubassoff,  Chambrelent,  Pyle,  Mars,  H.  von  Hoist,  and  others. 

Cholera. — Tarnier^  says  that  there  is  nothing  to  justify  the 
belief  that  cholera  affects  directly  the  fetus;  and  Queirel^  asserts 
that  it  is  doubtful  whether  cholera  can  be  conveyed  to  it,  but  early 
abortion  is  the  rule,  and  if  the  child  should  be  born  near  or  at 
term  it  dies  in  a  few  days. 

Typhoid  fever  is  usually  disastrous  to  the  fetus,  resulting  in 
its  premature  expulsion  in  about  sixty-five  per  cent,  of  the  cases.^ 
The  elevation  of  the  temperature,  the  alteration  of  the  blood, 
and  the  respiratory  embarrassment  are  considered  the  causes 
of  the  abortion  or  premature  labor.  But  that  the  disease  can 
affect  the  fetus  itself  has  been  shown  by  Neuhaus,*  who  found 
the  specific  bacilli  of  typhoid  fever  in  the  lungs,  spleen,  and  kidneys 
of  a  fetus  expelled  at  the  fourth  month  from  a  woman  who  was 
convalescing  after  a  prolonged  attack  of  the  disease.  Both  bacilli 
and  the  Widal  reaction  have  been  found  in  the  fetal  blood  (Lynch). 

In  30  cases  collected  by  Hicks  and  Frank  the  bacilli  were 
found  in  the  fetal  blood  in  15.^ 

Articular  Rheumatism. — There  are  two  instances  on  record  of 
the  transmission  of  the  disease  from  mother  to  fetus,  reported 
by  Pocock*'  and  Schaffer.'^  In  each  a  woman  affected  with 
articular  rheumatism  at  the  end  of  pregnancy  gave  birth  to  a 
child  presenting,  in  one  case  at  once,  in  the  other  at  the  end  of 
three  days,  all  the  symptoms  of  the  disease. 

Recurrent  Fever. — Albrecht*  has  described  three  cases  of  con- 
genital recurrent  fever,  and  in  the  blood  of  one  fetus  he  discov- 
ered the  spirilla. 

Yellow  Fever. — Bemiss,"  of  New  Orleans,  says  :  "  The  preg- 
nant woman  being  attacked  by  yellow  fever  and  recovering  with- 
out miscarriage,  immunity  from  future  attacks  is  conferred  upon 
the   offspring   contained   in  the   womb   during   the   attack." 

1  Loc.  cit.  2  u  Nouv.  Archiv  d'Obstet.  etde  Gynec,"  April  25,  1887,  p.  I. 

^  Duguyot,  "  Th^se  de  Paris,"  1879.  Sacquin's  statistics  show  interruption  of 
pregnancy  in  199  out  of  310  cases.      "These  de  Nancy,"  1885. 

*"  Berlin,  klin.  Wochens.,"  1886,  p.  389.  See  also  Speier,  "  Zur  Kasuistik 
des  placentaren  Ueberganges  der  Typhusbacillen  von  der  Mutter  auf  die  Frucht," 
Inaug.  Diss.,  Breslau,  1896.  Lynch,  "  Placental  Transmission,  with  the  Report  of 
a  Case  during  Typhoid  Fever,"  "John  Hopkins  Hospital  Reports,"  vol.  x,  Nos.  3, 
4,  and  5.     Exhaustive  bibliography. 

^  London  "  Lancet,"  Dec.  30,  1 905. 

^  London  "  Lancet,"  1882,  ii.  p.  804.       '  "  Berlin,  klin.  Wochens.,"  1SS6,  S.  79. 

^  "St.  Petersburg,  med.  Wochens.,"  1880,  No.  18,  and  1884,  p.  129. 

^  See  Parvin's  "Obstetrics,"  p.  222. 


THE   DISEASES   OF  THE  FETUS.  163 

Pneumonia. — The  placental  transmission  of  pneumococci  has 
been  demonstrated  in  a  number  of  instances,  resulting  in  a 
pneumococcus  septicemia  if  the  lung  has  not  expanded  or  in 
pneumonia  if  it  has.^ 

Non=infectious  Diseases  of  the  Fetus. — The  infectious  dis- 
eases are  transmitted  from  mother  to  fetus.  The  non-infectious 
diseases  have  an  independent  origin  in  the  latter.  It  appears 
occasionally,  however,  as  if  a  non-infectious  disease  occurring  at 
the  same  time  in  mother  and  fetus  were  transmitted  from  one  to 
the  other. 

Some  of  the  diseases  of  the  fetus  owe  their  origin  to  a  vitiated 
condition  of  the  maternal  blood,  to  an  inherent  weakness  in 
the  building  material  of  the  fetus,  as  in  cases  of  chronic  systemic 
affections  of  either  parent,  or  to  a  perverted  nervous  action  in 
the  mother.  Others  are  inexplicable.  Many  of  the  fetal  diseases 
are  interesting  only  to  the  pathologist,  but  a  few  deserve  some  notice 
here. 

Rachitis  ;   Chondrodystrophia   Foetalis  ;    Actiondroplasia Schor- 

lau  -  collected  the  records  of  forty-three  cases  of  congenital  rachitis, 
and  added  to  the  number  two  of  his  own;  while  Grafe^  mentions 
the  cases  that  have  been  described  by  Sandefort,  Winckler,  Schultz, 
Virchow,  Kehm,  and  Fischer;  Fehling*  and  Hennig^  have  also 
described  specimens  of  fetal  rachitis. 

Antenatal  rachitis  depends  upon  malnutrition;  but  the  fact  that 
the  mother  has  at  some  time  had  rachitis  herself,  as  evidenced  by 
the  shape  of  her  pelvis,  does  not  predispose  the  fetus  to  the  same 
affection.  The  appearance  of  a  rachitic  fetus  is  distinctive.  It 
has  an  enlarged  head,  perhaps  hydrocephaHc;  gaping  sutures  and 
fontanels,  a  "chicken"  breast  and  a  much  distended  abdomen; 
the  extremities  are  short,  thick,  and  often  bent  at  an  angle,  or 
curved,  and  the  joints  are  large  and  prominent.  The  spine  is 
often  curved  either  laterally  or  anteroposteriorly."  The  bones 
are  either  abnormally  hard  and  firm  or  so  brittle  that  they  are 
fractured  by  the  slightest  force.  This  condition  of  the  bones  in 
rachitis  may  be  simulated  by  the  arrest  of  bony  development  in 
cases  of  sporadic  fetal  cretinism.'  Bidder  and  Aliiller  have  de- 
scribed bone  diseases  in  the  fetus  which  a])pear  to  be  varieties  of 
rachitis. 

1  Levy,  "Arch.  f.  experiment.  Path."  Bd.  xxvi,  and  Netter,  "  Comp.  rend. 
Biol.,"  May  15,  18S9. 

'^  "  Monatschr.  f.  Geburtsh.,"  Bd.  xxx,  S.  401. 

3  "Arch.  f.  Gyn.,-'  Bd.  viii,  S.  500.  *  li'id.,  Bd.  x. 

5  "  Transactions  of  Meeting  of  German  Naturalists  and  Physicians,"  Berlin, 
1886. 

"  Grafe,  loc.  tit. 

'  Virchow's  "Archiv,"  Bd.  c,  S.  256. 


164 


PREGNANCY. 


Chondrodystrophia  jcetaUs  or  achondroplasia  depends  upon  an 
arrest  of  development  in  the  epiphyses,  with  a  consequent  shorten- 
ing of  the  long  bones  of  the  extremities.     The  appearance  of  the 


Fig.  118. — Chondrodystrophia  fetalis. 

fetus  suggests  rachitis,  but  an  examination  of  the  skeleton  estab- 
lishes the  diagnosis.^ 

Anasarca. — General  anasarca  of  the  fetus  is  occasionally  seen. 
The  distention  of  the  fetal  skin  may  reach  such  dimensions  that 
the  expulsion  of  the  child  is  exceedingly  difficult.^  Such 
children  are,  however,  usually  born  prematurely  from  the  fourth 
to  the  eighth  month,  and  are,  as  a  rule,  still-born,  although 
cases  are  recorded  in  which  they  lived  for  a  short  time  after 
birth.  The  causes  of  this  condition  must  be  various.  It  has 
been  attributed  to  anasarca  of  the  mother,  to  syphilis,  to  absence 
of  the  thoracic  duct ;  ^  in  one  instance  to  leukemia  of  the  fetus,* 
in  another  to  obstruction  of  the  umbiHcal  vein.^  The  serous 
infiltration  of  the  skin  is  usually  accompanied  by  a  collection  of 
fluid  in  the  abdominal  and  pleural  cavities,  and  the  membranes 
and  placenta  are  often  markedly  edematous. 

1  '<  Handbuch  d.  Geburtsh.,"  F.  v.  Winckel,  II.,  2,  1905. 
■•^  Keiller,  "  Edinburgh  Med.  and  Surg.  Jour.,"  April,  1855. 
3  "  The  Diseases  of  the  Fetus,"  Ballantyne,  Edinburgh,  1895,  2  vols.     Complete 
bibliography. 

*  Klebs,  "  Prager  nied.  Wochens.,"  1878,  No.  49. 
5  "  Breslauer  Klin.,"  Bd.  i,  S.  260. 


THE  DISEASES   OE  THE   FETUS.  1 65 

Congenital  Cystic  Elephantiasis. — In  this  disease  there  is  a 
great  overgrowth  of  the  subcutaneous  connective  tissue  all  over 
the  body,  and  at  intervals  in  the  hypertrophied  tissue  there  are 
cysts  varying  in  size.  Malformations  of  a  grave  character  are 
commonly  associated  with  the  disease.  The  infants  scarcely 
ever  survive  their  birth.  One  child,  however,  lived  thirty  min- 
utes and  another  was  twenty  months  old  when  the  case  was  re- 
ported. Ballantyne  ^  has  collected  more  than  eighteen  cases  of 
this  very  rare  disease. 

Spontaneous  Fractures  in  Utero. — The  fetal  bones  may  be 
broken  by  external  violence,  or  a  child  may  be  born  presenting 
numerous  fractures,  especially  of  the  long  bones,  either  recent 
or  already  undergoing  repair,  without  the  history  of  an  accident 
of  any  kind  to  the  mother  during  pregnancy.  If  in  such  cases 
one  can  exclude  a  syphilitic  osteochondritis,  Avith  a  separation 
of  the  epiphysis  and  diaphysis,  or  an  injury  to  the  child  during 


Fig.  119. — Congenital  cystic  elephantiasis. 

labor,  there  must  have  been  a  rachitic  condition  of  the  bones  or 
an  arrest  of  ossification,  to  allow  of  fracture  by  the  slight  force 
which  could  be  exerted  by  the  fetal  muscles  or  the  pressure  of 
the  uterine  walls.  Link  ^  describes  a  case  of  numerous  frac- 
tures in  utero  of  the  ribs,  clavicle,  and  extremities,  in  which 
syphilis,  rachitis,  and  chronic  parenchymatous  osteitis  could  be 
excluded,  and  he,  therefore,  concludes  tliat  tlicse  fractures  were 

^  "  Diseases  of  the  Fetus,"  Edinb.,  1895,  2  vols. 

2  "  Archiv  f.  Gyn.,"  Bd.  x.xx,  2,  p.  264,  1887.  ■ 


1 66  PREGNANCY. 

caused  by  an  "  unknown  intra-uterine  fetal  bone  disease,"  in 
which  the  bones  became  soft  and  brittle.  A  similar  bone  disease 
has  been  described  by  Schmidt. 

Luxations  and  Ankylosis. — Luxations  affect  females  four 
times  as  often  as  males,  ^  and  are  much  more  common  in  the 
lower  than  in  the  upper  extremities.  An  apparent  ankylosis  ^ 
after  birth  occasionally  appears  when,  in  breech  presentations, 
the  presenting  part  has  remained  a  long  time  in  the  cavity  of  the 
pelvis.  The  lower  limbs  remain  in  the  position — of  flexion  of 
thighs  upon  abdomen  and  extension  of  legs  upon  the  thighs — 
that  they  occupied  in  utcro,  and  it  is  impossible  for  a  while  to 
restore  them  to  a  proper  position.^ 

Intestinal  Invagination. — Lauro^  has  described  a  double 
invagination  of  the  descending  colon  during  intra-uterine  life. 

Intra=uterine  amputations  are  rare.^  They  are  usually  due  to 
amniotic  bands.  But  this  explanation  will  not  sufQce  for  all  cases. 
It  has  been  demonstrated  that  a  gangrenous  process "  at  a  certain 
point  in  the  limb  may  determine  an  amputation,  just  as  it  would 
in  extra-uterine  life,  or  that  a  peculiar  morbid  process  ^  may  produce 
a  constriction  from  the  circular  contraction  of  connective  tissue 
at  a  certain  point,  or,  again,  that  an  amputation  ^  may  follow  a 
fracture.  The  amputated  part  may  float  loose  in  the  amniotic 
liquid,  may  possibly  be  absorbed  if  detached  early  in  embryona-l 
life,  or  may  be  attached  to  the  sound  portion  of  the  Hmb  by  a 
filament. 

Fetal  Traumatism. — The  fetus  is  well  protected  from  external 
violence,  but  it  may  experience  injuries  of  the  gravest  nature,  either 
in  connection  with  serious  injury  to  the  mother  or  occasionally  with 
very  slight  evidences  of  violence  to  the  maternal  tissues.  Thus, 
in  cases  of  gunshot,  ^  stab,i*^  or  other  perforating  wounds  of  the 
abdomen  in  pregnant  women,  the  fetus  has  likewise  been  severely 

1  Tarnier  et  Budin,  loc.  cit. 

2  Lefour,  "Presentation  du  Siege  decomplete  Mode  des  Fesses,"  Paris,  1882. 

3  The  fixation  of  the  limbs  or  trunk  in  abnormal  positions  by  muscular  contrac- 
tion may  occur  in  utero  during  pregnancy,  as  in  the  interesting  case  of  "contracture" 
in  utero  (Ribemont-Dessaigne,  abstract  in  "  Nouv.  Archiv  d'Obstet.,"  Sept.,  1887). 
In  this  connection  the  student  should  consult  alse  the  paper  by  Matthews  Duncan  on 
"Extensions  and  Retroflexions  of  the  Fetus,  especially  of  the  Trunk,  during  Preg- 
nancy" ("Trans.  London  Obstet.  Soc. ,"  xxvi,  1884,  p.  206) 

*  "Annali  di  Ostet.  e  Ginecol.,"  Luglio-Agosto,  1887. 

*  For  an  extensive  bibliography  see  Tarnier  et  Budin. 

^  Chaussier,  "  Proces  verbal  de  la  Distribution  des  Prixes  a  la  Maternity,"  1822. 
^  Kristeller,  "  Monatschr.  f.  Geburtsh.,"  Bd.  xiv,  p.  817. 

8  Martin,  "  Gaz.  Hebdom.,"  1858,  p.  384. 

9  Hays,  "Ann.  de  Gyn.,"  1880,  xiii,  p.  153. 

lopennell,  "Trans.  N.  Y.  Path.  Soc,"  iii,  249;  Tarnier  et  Budin,  loc.  cit.,  p. 
345;  Guelliot,  "Gaz.  des  Hop.,"  1886,  p.  405. 


THE   DISEASES    OF   THE   FETUS.  1 67 

and  fatally  wounded.  Also,  in  the  performance  of  celiotomy, ^  by 
a  mistaken  diagnosis  the  trocar  that  was  plunged  into  what  was 
thought  to  be  an  ovarian  cyst  has  penetrated  the  fetus,  and  wounds 
have  been  inflicted  by  both  sharp  and  dull  instruments  ignorantly 
used  to  bring  on  an  abortion  or  in  the  hands  of  physicians  who 
overlooked  the  condition  of  pregnancy.  On  the  other  hand,  as 
instances  of  fatal  injur\^  to  the  fetus  without  apparent  injury,  ex- 
ternally, at  least,  to  the  mother,  might  be  cited  the  cases  of 
Mascka  ^  and  Gurlt,  ^  in  which  the  cranial  bones  of  the  fetus 
were  fractured  by  the  mother  falling  from  a  height,  or  the  case 
described  by  G.  von  Hoffman, ^  of  a  woman  in  the  fifth  month  of 
pregnancy  who  threw  herself  out  of  a  fourth-story  window  and 
was  killed  by  the  fall,  although  she  exhibited  no  signs  of  external 
injury  ;  the  uterus  was  uninjured,  and  the  fetus  externally  was  ap- 
parently unharmed,  but  on  opening  its  abdomen  the  liver  was  found 
almost  disintegrated.  The  case  reported  by  Lumley  ^  shows 
more  clearly  how  slight  violence  to  the  mother  may  be  fatal  to 
the  fetus  :  A  pregnant  woman,  within  ten  days  of  term, 
attempting  to  enter  a  doorway,  slipped  and  struck  the  left  lower 
portion  of  her  abdomen  against  the  edge  of  the  door.  The 
movements  of  the  child  thereupon  ceased,  and  eight  days  after- 
ward a  dead  fetus  was  born  with  a  fracture  of  the  left  frontal  and 
parietal  bones  of  the  skull.  One  of  my  patients  was  thrown 
from  a  carriage  two  months  before  her  delivery.  Her  infant, 
otherwise  healthy,  had  a  fractured  clavicle,  almost  entirely  healed, 
but  with  a  large  mass  of  callus  about  the  site  of  fracture. 

These  cases  of  fetal  injury  are  not  only  interesting  from  their 
rarity,  but  they  are  also  important  from  a  medicolegal  point  of 
view.  Thus,  Gorhan^  records  the  death  of  a  fetus  from  violence 
done  the  mother  at  the  hands  of  another  woman  in  the  course  of 
a  brutal  quarrel  between  two  sisters-in-law,  during  which  the 
pregnant  woman,  being  at  the  time  in  the  sixth  month  of 
gestation,  was  thrown  to  the  ground  and  stamped  upon  by  her 
infuriated  relative.  Two  months  afterward  a  dead  fetus  was 
born,  corresponding  in  development  to  the  sixth  month  of 
pregnancy,  and  exhibiting  a  transverse  fracture  of  both  parietal 
bones.  A  young  girl  illegitimately  pregnant,  under  m}' charge  in 
the  Maternity  Hospital,  ran  a  long  hat-piii  up  to  its  head  into  her 

1  Goodell,  "  Lessons  in  Gynecology,"  p.  352. 

2  "Prager  Vierteljahrschrift,"  1857. 

8  "Monatsch.  f.  Geburtsh.,"  1857,  p.  343. 

4  "Wien.  med.  Presse,"  xxvi,  1885,  Nos.  18,  20,  etc. 

»  "N.  Y.  Med.  Rec,"  1886,  p.  359. 

«J.  Taber  Johnson,   "Trans.  Am.  Gyn.  Soc,"  vol.  iii,  p.  107. 


l68  PREGNANCY. 

abdomen  at  the  umbilicus.  She  transfixed  her  fetus,  which  was 
born  dead  a  {&^  days  later.  She  suffered  no  other  inconvenience 
than  a  slight  purulent  discharge  from  the  umbilicus.  It  might 
be  important  to  distinguish  injuries  experienced  during  labor,  as 
fractures  of  the  extremities  or  of  the  spine, ^  or  depressions  of 
the  skull, 2  from  the  effects  of  traumatism  during  pregnancy. 

Conditions  of  the  Mother  Which  Injuriously  Affect  the 
Fetus. — The  Influence  of  Maternal  Fever  upon  the  Fetus.^ — The 
well-known  experiments  of  Runge,^  published  in  1877,  were  for 
some  time  accepted  as  conclusive  proof  of  the  great  danger  to 
the  fetus  of  high  temperature  in  the  mother.  Pregnant  rabbits 
placed  in  a  hot  box  until  their  body -temperature  had  risen  to 
105.8°  usually  died,  and  almost  invariably  the  fetuses  were  found 
dead  upon  opening  the  animal's  body  immediately  after  its  re- 
moval from  the  box.  But  in  1883  Doleris^  showed  that  if  the 
temperature  of  the  animals  was  slowly  raised  to  105°  or  106°, 
and  not  within  an  hour,  as  in  Runge's  experiments,  they  seemed 
to  bear  it  without  much  inconvenience,  even  if  long  continued, 
and,  if  pregnant,  their  young  remained  perfectly  healthy.  These 
results  were  confirmed  by  Runge^  in  a  second  set  of  experiments, 
in  which  he  found,  however,  that  if  the  animal's  temperature  was 
raised,  even  very  gradually,  to  109.4°,  there  occurred  the  same 
symptoms — death  of  the  fetus  and  heat-stroke  of  the  mother — 
as  though  the  temperature  had  been  quickly  raised  to  106°. 
Preyer^  has  also  shown  that  the  fetus  is  capable  of  enduring  a 
much  higher  temperature  than  was  formerly  supposed,  for  in  one 
instance  he  actually  observed  a  fetal  temperature,  in  a  guinea-pig, 
of  111.2°,  taken  in  ano,  the  fetus  living  nine  minutes,  or  until 
the  cord  was  severed  and  it  was  removed  from  the  uterus.  In 
view,  therefore,  of  these  experiments,  it  seems  necessary  to  modify 
the  views  formerly  entertained,  that  the  existence  of  fever  in  the 
mother  must  of  itself  necessarily  threaten  the  life  of  the  fetus, 
unless,  indeed,  the  temperature  should  rise  suddenly,  as  in  the 
case  of  brain-tumor  described  by  Runge,  or  in  cases  of  recurrent 
fever  recorded  by  Kaminski,'^  or  else  should  reach  an  extreme 
height,  as  it  might  in  insolation. 

As  to  the  treatment  of  fever  in  pregnant  women  with  a  view 
to  its  influence  on  the  fetus,   no  special  measures  are  required 

1  "  Wien.  med.  Presse,"  xxvi,  p.  370. 

2  There  are,  however,  two  recorded  cases  of  this  injury  occurring  from  traumatism 
during  pregnancy.  ^  "Archiv  f.  Gyn.,"  Bd.  xii,  p.  l6  ;   Bd.  xiii,  p.    123. 


result 

and  by  Negri  (s 

5  "Archiv  f.  Gyn.,"  Bd.  xxv,  S.  i. 

«  "Physiologie  des  Embryo,"  Leipzig,  1884. 

■^  "St.  Petersburg  med.  Zeitung,"  1868,  117. 


THE   DISEASES   OE   THE   EETUS.  1 69 

SO  long  as  the  temperature  rises  gradually  and  remains  under 
105°,  but  above  this  point  the  danger  to  the  fetus  begins  (Kam- 
inski),  and  active  antipyretic  treatment  is  required.  Should  a 
pregnant  woman  die  with  a  temperature  as  high  as  109°,  the 
performance  of  postmortem  Cesarean  section  would  be  useless, 
for  the  fetus  would  inevitably  die  first,  having  no  means  of  getting 
rid  of  its  extra  heat  by  radiation.  The  operation  would  likewise 
be  futile  in  a  case  of  death  after  a  very  sudden  rise  of  tempera- 
ture (Runge). 

The  Influence  of  Maternal  Emotions  upon  the  Fetus. — Maternal 
emotions  and  impressions  may  possibly  affect  the  embryo  or  fetus. 
Many  cases  of  mental  peculiarities  or  diseases,  or  of  physical 
defects,  that  have  been  attributed  to  a  strong  impression  upon 
the  mother  during  pregnancy,  are  explained  by  the  existence 
of  some  systemic  disease,  as  syphilis,  nephritis,  diabetes,  cancer, 
or  chronic  lead-poisoning  in  either  father  or  mother  ;  by  an  arrest 
of  development ;  by  mechanical  disturbance  of  the  ovum,  or,  in 
the  case  of  intra-uterine  amputations,  by  the  formation  of  amniotic 
bands  or  the  disposition  of  the  cord  ;  but  there  still  remain  well- 
authenticated  cases  of  congenital  defects  or  peculiarities,^  which 
bear  too  startling  a  resemblance  to  the  cause  of  the  impression 
upon  the  mother  during  pregnancy  to  be  dismissed  as  mere  coin- 
cidences. One  of  my  patients,  less  than  six  weeks  pregnant, 
was  seized  by  the  ear  and  dragged  about  the  room  by  her  en- 
raged husband.  The  child  born  at  term  had  a  triangular  piece 
lacking  from  the  lobe  of  the  corresponding  ear. 

A  strong  emotion  on  the  part  of  the  mother  may  be  immedi- 
ately fatal  to  the  fetus.  ^  Profound  impressions  upon  the  mother 
certainly  influence  the  psychical  development  of  her  offspring. 
The  idiocy  of  Barnaby  Rudge  due  to  maternal  shock  and  fright  is 
a  fiction  founded  upon  fact.  The  horror  of  King  James  at  the 
sight  of  a  naked  sword  may  well  have  had  its  origin  in  the  murder 
of  Rizzio  before  the  eyes  of  the  pregnant  Queen  Mary. 

There  is  no  question  that  certain  maternal  conditions  may  so 
modify  the  blood  in  its  capacity  of  a  bearer  of  oxygen  and 
nutriment  to  the  fetus  as  to  seriously  interfere  with  the  latter's 
health,  if  not  to  destroy  its  existence.  Such  is  undoubtedly  the 
case  in  pneumonia  of  the  mother,  which  can  jirevent  a  proper 
aeration  of  the  maternal^  and  consequently  of  the  fetal,  blood, 
and  may  so  bring  about  complete  asphyxia  of  the  fetus,  or  may, 
perhaps,  result  in  inspiratory  efforts///  ntcro,  the  inspiration  of 
liquor  amnii,  and  a  subsequent  development  of  pneum<>nia  in  the 

^  See  the  very  interesting  paper  by  Dr.  P'ordyce  Baker  in  "  (Jynecul.  Trans.," 
vol.  xi,  1886. 

2  "Lancet,"   vol.  ii,  1874. 


I/O  PREGNANCY. 

fetus  itself.^  Whatever  the  cause  of  death,  pneumonia  in  the 
mother  is  exceedingly  fatal  to  the  fetus. 

In  infectious  diseases  the  development  of  specific  micro- 
organisms in  the  maternal  blood  may  so  alter  its  normal  con- 
stitution as  to  render  it  unfit  for  the  respiratory  and  nutritive 
needs  of  the  fetus. 

Icterus  gravidarum  endangers  the  life  of  the  fetus,  either  by 
bringing  on  an  abortion  or  by  first  destroying  its  life  by  the 
poisonous  action  of  the  bile-salts,  ^  or,  perhaps,  by  the  induction 
of  cholemic  convulsions.  ^  Thus,  Spath  *  describes  8  cases,  in 
4  of  which  the  fetus  was  born  dead  ;  and  Frerichs  ^  mentions 
3  cases,  all  fatal  to  the  fetus.  Saint  Vel  ^  has  described  an  epi- 
demic of  jaundice  on  the  island  of  Martinique.  Of  30  preg- 
nant women  affected,  20  were  delivered  prematurely,  and  of 
these  20  children  19  were  either  still-born  or  died  shortly 
after  birth.  Bardinet"^  has  also  recorded  the  birth  of  6  dead 
infants  out  of  13  pregnant  women  who  were  suffering  from 
jaundice  during  an  epidemic  of  the  disease  in  Limoges.  Fre- 
quently as  the  bile-salts  must  traverse  the  uteroplacental  septum 
and  enter  the  fetal  circulation,  as  evidenced  by  the  high  per- 
centage of  still-born  children  in  women  afiected  with  jaundice 
during  pregnancy,  the  coloring-matter  of  the  bile  seldom  stains 
the  fetal  tissues.  Lomer^  collected  56  cases  in  which  naturally 
colored  children  were  born  of  jaundiced  mothers,  and  43  more 
in  which  the  color  of  the  child  was  not  mentioned,  so  that 
it  was  presumably  natural ;  and  to  these  might  be  added  another 
case  described  by  Parrish.  There  are  6  recorded  cases,  however, 
in  which  the  fetus  or  the  whole  ovum  was  undoubtedly  jaun- 
diced (Lomer). 

Eclampsia. — It  has  been  estimated  that  about  one-half  the 
children  are  still-born  after  the  eclampsia  of  pregnancy  or  labor. 
The  cause  of  fetal  death  is  the  carbonic-oxid  gas  in  the  maternal 
blood,  the  stagnation  of  the  blood-current  during  a  con\ailsion,  or 
the  toxins  in  the  blood. 

Tlie  death  of  the  mother  kills  the  fetus,  but  not  necessarily  at 
once.     Life  may  continue  in  the  fetus  for  some  time  after  it  is 

^  See  Inspiration  Pneumonia. 

2  Valenta,  "  Oesterreichische  Jahrb.,"  xviii,  1869,  S.  163. 

^  Stumpf,  "  Archiv  f.  Gyn.,"  Bd.  xxviii,  11.  3. 

4  "  Wiener  med.  Wochens.,"  1854,  S.  757. 

«  "  Klin,  der  Leberkrankheit.,"  1858,  Bd.  i. 

6  "Gaz.  des  Hop.,"  1862,  p.  538. 

''  "  Union  Medicale,"  1863,  Nos.  133  et  134. 

8  "Zeit.  f.  Geburtsh.,"  xiii,  p.  169,  1886. 


THE   DISEASES   OF   THE   FETUS. 


171 


extinct  in  the  mother.  Kergaredec's  view  that  twenty-four  hours 
might  elapse  between  the  death  of  the  mother  and  the  fetus  is  pre- 
posterous. There  is  on  record,  however,  a  well-authenticated  case 
of  the  extraction  of  a  living  child  from  the  womb  of  a  woman  who 
had  been  dead  two  hours.^  Tarnier^  performed  a  postmortem  Cesa- 
rean section  upon  a  woman  who  during  the  Commune  in  Paris  had 
been  killed  by  a  stray  bullet  in  the  wards  of  the  Maternite,  and 
extracted  a  living  child,  certainly  three-quarters  of  an  hour — 
perhaps  an  hour  and  a  quarter — after  the  death  of  the  mother. 
Numerous  other  instances  are  recorded  of  postmortem  Cesarean 
operations,  or  the  extraction  of  infants  per  v.ias  iiaturales,  at  inter- 
vals of  time  ranging  from  a  few  minutes  to  a  half  hour  after  the 
death  of  the  mother.  The  remarkable  survival  of  the  fetus  under 
conditions  which  would  seem  to  make  life  impossible  is  explained, 
perhaps,  by  the  cases  of  children  born  asphyxiated,  whose  hearts 
continue  to  beat,  although  they  do  not  breathe  for  a  long  time 
after  birth,  or  by  the  experiment  performed  by  Haller  ^  of  forc- 
ing a  bitch  to  give  birth  to  her  pups  under  water,  where  they 
crawled  about  and  lived  for  half  an  hour. 

The  death  of  the  fetus   may  be  due  to  many  causes.     It 
may  be  the  result  of  injuries,   deformities,   or  diseases  in  the 
fetus  itself,  or  in  its  appen- 
dages, the  membranes,  and  .  - 
the    placenta.       It  may   be              .^^^^^bk 
due  to  inherent  weakness  in           .^^^|9k^<^^^  J 
either  the  ovule  or  the  sper- 
matic   particle,   Avhich   does 
not  prevent  conception,  but 
renders  the  embryo  incapa- 
ble of  development  beyond 
a  certain  point ;  or  it  may  be 
the    consequence  of  a  mis- 
placed  ovum,   as    in    tubal, 
ovarian,  and  abdominal  preg- 
nancies.    The  condition  of 

the  maternal    blood,  the  ex-    Fig.    120.— Two  years  in  tin-  abdomen  (P,aei). 

istence  of  a  very  high  tem- 
perature  in   the  mother,  and   perhaps  strong  emotions,  are  occa- 
sionally responsible  for  the  destruction  of  fetal    life.     All   these 
conditions  have  been  or  will  be  considered   in  their  appropriate 
places  ;  but  it  remains  to  notice  the  effect  of  fetal  death  upon  the 


1  Huberl,    "  Traite  d' Accoucliements,"  vol.  ii,  p.   i6o. 

2  Tarnier  et  Budin,  ii,  p.  571. 

3  "Elem.  Physiol.,"  vol.  iii,  p.  314,  quoted  in  Tarnier  et  Budin,  op.  cit.,  p.  570. 


1/2 


PREGNANCY. 


mother,  the  diagnosis  of  fetal  death,  the  habitual  death  of  the 
fetus,  and  the  changes  that  ensue  in  the  fetus  itself  after 
death. 

The  effect  of  the  death  of  a  fetus  upon  its  mother  is  often 
nil.  There  may  be  depression,  loss  of  appetite,  and  chilly  sen- 
sations. When  the  dead  body  putrefies,  or  when,  after  absorp- 
tion of  the  soft  parts  there  is  an  attempt  to  discharge  the  fetal 
bones  by  ulceration  into  the  bladder,  vagina,  rectum,  or  exter- 
nally through  the  abdominal  walls,  the  mother's  health  and 
safety  are  seriously  endangered.  Thus,  after  ectopic  gestation 
the  dead   fetus  may  remain   for  an  indefinite   period  within  the 


Fig.  121. — Calcification  of  cap- 
sule (in  abdomen  unknown  length  of 
time). 


Fig.     122. — Lithopedion.     Two   years 
in  abdomen  (Baer). 


mother's  abdomen  with  no  inconvenience  except  the  enlargement 
of  the  abdomen;  but  should  the  germs  of  putrefaction  gain  access 
to  the  dead  body,  as  they  may  by  reason  of  the  contiguity  of  the 
intestines  (Litzmann),  then  a  general  suppurative  peritonitis  may 
be  developed  and  rapidly  prove  fatal.  So,  too,  in  the  retention  of 
bhghted  ova^  or  in  cases  of  missed  labor^  there  is  usually  no  evi- 
dence of  serious  harm  to  the  mother  until  the  putrefaction  of  the 
dead  body  begins,  when  there  may  be  shortly  manifested  all  the 
symptoms  of  septicemia,  unless  the  uterine  cavity  is  speedily 
cleared  of  its  contents  and  well  disinfected. 


1  See  Gehrung,  "Weekly  Med.  Review,"  Chicago,  1885,  p.  131 ;  "Westmins- 
ter Hospital  Reports,"  1885, i,  119;  *'TokioMed.  Journ.,"  1S86,  No.  439.  Graefe, 
in  Ruge's  "Festschrift";  Stager,  Inaug-Diss.,  Bern,  1895. 

2  Lusk,  "  Science  and  Art  of  Midwifery,"   1S86,  p.  304. 


THE   DISEASES   OF   THE  FETUS.  1 73 

It  is  not  easy  to  determine  that  the  fetus  is  dead.  If  death  oc- 
curs during  early  pregnane}-,  the  uterus  usually  ceases  to  grow  and 
the  circumference  of  the  abdomen  no  longer  increases  steadily  from 
week  to  week  ;  the  breasts  soon  become  flabby,  although  it  is  not 
rare  for  milk  to  appear  for  a  time  after  the  death  of  the  fetus  ;  the 
woman  may  complain  of  subjective  symptoms,  as  a  feeling  of 
weight  and  discomfort  in  the  hypogastric  region  (Lusk)  ;  but  doubt 
is  usually  soon  solved  by  the  expulsion  of  the  ovum.  Should  the 
fetus  die  in  the  later  months  of  pregnancy,  the  movements, 
theretofore  perhaps  active,  are  no  longer  felt  by  the  mother,  and 
the  fetal  heart-sounds  are  no  longer  heard.  Neither  of  these 
signs,  however,  is  entirely  reliable,  for  the  woman's  statement 
is  not  always  perfectly  credible,  and  it  is  impossible  occasion- 
ally to  hear  the  fetal  heart-sounds,  although  the  child  is  alive 
and  well.  The  urine  of  the  mother  commonly  undergoes  a 
change  after  fetal  death.  Albuminuria  sometimes  disappears 
when  the  fetus  dies.  On  the  contrary,  I  have  seen  albuminuria 
appear  in  consequence  of  fetal  death.  Peptonuria  may  be  looked 
for  if  there  is  decomposition  of  the  fetal  body,  and  acetonuria,  it 
is  claimed,  is  an  invariable  consequence  of  a  dead  fetus  in 
utcro.'^  The  statement  is  made  that  the  urobilinuria,  present  in 
all  pregnant  women,  is  always  more  exaggerated  in  the  first  few 
days  after  fetal  death.  ^  Negri  ^  was  able  to  make  the  diagnosis 
of  fetal  death  during  pregnancy  by  abdominal  palpation,  the  fetus 
presenting  a  rather  confused  outline  and  giving  rise,  upon  pres- 
sure on  the  mother's  abdomen  over  the  region  of  the  fetal  head, 
to  an  indistinct  crepitus.  During  labor  a  doubt  may  arise  as  to 
whether  the  fetus  is  dead  or  aHve,  and  upon  the  decision  often  de- 
pends the  performance  of  embryotomy  or  of  a  more  conservative 
operation.  It  has  been  suggested  by  Cohnstein  *  and  Fehling  ^ 
that  if  the  temperature  of  the  uterus  is  no  higher  than  that  of  the 
vagina,  the  child  may  safely  be  pronounced  dead  ;  for  the  living 
fetus,  having  a  higher  temperature  than  its  mother,  imparts  some 
additional  heat  to  the  maternal  structures  about  it.  Priestley  *' 
more  practically  suggests  that  the  hand  be  introduced  into  the 
uterus  in  order  to  feel  in  the  precordial  region  for  the  impulses 
of  the  fetal  heart,  or  to  feel  the  pulsations  in  the  cord. 

1  Acetonuria  was  found  9  times  in  139  pregnant  women,  and  in  each  of  the  9 
cases  it  was  demonstrated  that  the  woman  was  cariying  a  dead  fetus.  Vicasella, 
*' Wien.  med.  Presse,"  1S94,  p.  205. 

2  Merletti,  "  Centralbl.  f.  Gyn.,"  No.  16,  1902. 

8  "  Annali  di  Ostetricia,"  May,  June,  1885,  p.  223. 

4  "  Archiv  f.  Gyn.,"  Rd.  iv,  II.  3. 

5  Tbid.,  Bd.  vii,  S.  143. 

^  "Lancet,"  Jan.  23,  1S87. 


174  PREGNANCY. 

After  death  the  fetal  tissues  in  time  saponify  (adipocere), 
partially  calcify,  mummify,  or  else  are  totally  or  partially  ab- 
sorbed. Shortly  after  death  there  may  be  maceration  and 
putrefaction.  Before  the  second  month  the  product  of  con- 
ception may  be  entirely  absorbed.  After  that  time  the 
changes  that  take  place  depend  to  some  extent  upon  the  posi- 
tion of  the  fetus.  Within  the  uterus  the  dead  fetus  is  first 
macerated,  becoming  bloated  in  appearance,  with  a  grayish- 
colored  skin  deprived  of  its  epidermis  in  spots  of  varying 
extent ;  the  head  is  enlarged,  the  cranial  bones  are  loose 
under  the  scalp,  and  the  tissues  become  so  soft  and  friable  that 
very  slight  force  is  sufficient  to  detach  the  limbs  from  the  body. 
If  saprophytes  gain  access  to  the  fetus,  in  this  condition  by  rup- 
ture of  the  membranes,  decomposition  rapidly  ensues.  The 
other  changes  that  affect  .the  fetal  tissues  after  death  are  a  sap- 
onification, and  possibly  mummification,  in  which  latter  state 
they  will  remain  for  an  indefinite  period  without  change. 
It  is  in  abdominal  pregnancies  that  the  dead  fetus  becomes 
converted  into  a  so-called  lithopedion,  which  consists  not 
of  a  calcification  of  the  whole  mass,  but  (i)  of  a  calcification  of 
the  membranes  after  absorption  of  the  liquor  amnii ;  (2)  of  a  cal- 
cification of  the  membranes  and  those  points  on  the  fetus  where 
the  membranes  adhere  to  the  fetal  surface  ;  or  (3)  of  a  deposition 
of  lime  in  the  vernix  caseosa  after  the  membranes  have  been 
ruptured  and  the  fetus  has  escaped  into  the  abdominal  cavity,  ^ 
The  fetus  in  the  abdominal  cavity  may  undergo  all  the  other 
changes  that  have  been  described,  including  putrefaction,  and, 
in  addition,  the  soft  parts  may  be  absorbed,  the  bony  skeleton 
remaining  as  a  foreign  body  in  the  abdomen  until  it  is  discharged 
piecemeal,  through  openings  into  the  bladder,  intestines,  rec- 
tum, uterus,  and  vagina,  or  externally  through  the  abdominal 
walls. 

The  Habitual  Death  of  the  Fetus. — There  are  women  who 
in  two  or  more  successive  pregnancies,  usually  at  the  same 
period  in  each,  give  birth  to  dead  children.  It  is  important  to 
learn,  if  possible,  the  cause  of  the  repeated  fetal  death,  for  upon 
it  depends  the  treatment  adopted  to  secure  the  birth  of  a  living 
child. 

Although  by  no  means  the  only  cause  of  the  habitual  death 
of  the  fetus  syphilis  is  by  far  the  most  frequent.  According  to 
Ruge's^  estimate,  eighty-three  per  cent,  of  repeated  premature 
and  still-births  are  due  to  syphilis  in  one  or  both  of  the  parents. 

1  Kiichenmeister,  "Archiv  f.  Gyn.,"  Bd.  xvii,  p.  153. 

2  "Zeit.  f.  Geburtsh.,"  Bd.  i. 


THE  DISEASES   OF   THE   FETUS.  1 75 

But  there  are  many  cases  in  which  s}T3hihs  can  with  certainty 
be  excluded,  and  in  which  the  death  must  be  ascribed  to  other 
causes. 

Certain  Conditions  of  the  Uterus  which  Interfere  with  the 
Development  of  the  Fetus. — There  are  no  reHable  statistics  in 
regard  to  the  relative  frequency  of  the  causes,  other  than  syphilis, 
of  habitual  death  of  the  fetus,  but  I  should  place  first  chronic  endo- 
metritis and  chronic  metritis,  which  interrupt  pregnancy,  either  by 
effusions  of  blood  into  the  hyperemic  mucous  membrane,  and  the 
consequent  excitation  of  muscular  action  in  the  uterus,  or  by  an 
active  growth  of  the  decidua  and  the  diversion  of  the  nutritive 
blood-supply  from  the  fetus  to  the  uterine  mucous  membrane.^ 

Abarbanell  ^  first  called  attention  to  chronic  metritis  as  a 
cause  of  habitual  abortion,  from  the  excessive  development  of 
fibrous  tissue  in  the  body  of  the  uterus,  which  by  loss  of  elas- 
ticity would  interfere  with  a  sufficient  dilatation  of  the  uterine 
cavity.  Such,  perhaps,  is  the  explanation  of  Baudelocque's 
case,  ^  in  which,  after  a  Cesarean  section,  a  woman  successively 
gave  birth  to  four  children  at  the  seventh  month  of  pregnancy. 
In  two  cases  under  my  observation  an  ill-developed  uterus  was 
the  cause  of  repeated  premature  births.  In  one  the  woman  gave 
birth  to  thirteen  children  at  the  sixth  month,  none  of  which  sur- 
vived. In  the  other  there  were  three  premature  births  before  the 
children  were  viable.  In  this  woman  menstruation  began  in  the 
eighteenth  year  ;  there  were  long  periods  of  amenorrhea,  and  a 
vaginal  examination  before  marriage  revealed  an  infantile  uterus. 

Alterations  in  the  Maternal  Blood  that  are  Fatal  to  the 
Fetus. — Scanzoni  ^  pointed  out  that  a  high  grade  of  anemia  in 
a  pregnant  woman  might  be  fatal  to  the  fetus.  The  anemia  may 
be  due  to  an  exaggeration  of  the  hydremia  which  is  character- 
istic of  pregnancy,  or  to  the  development  of  pernicious  anemia  ;  ^ 
to  sudden  loss  of  blood,  or  to  lack  of  proper  or  sufficient  food. 
To  this  last  cause  may  be  attributed  the  large  number  of  abor- 
tions and  still-births  that  occurred  during  the  siege  of  Leyden 
(Hoffmann),  or  in  Germany  during  the  year  1826,  when  the 
crops  failed  CNagele),  and  during  the  siege  of  Paris  (Priestley). 

Plethora  might  possibly  prove  a  predisposing  cause  to  effusion 
of  blood  into  the  membranes  or  placenta,  especially  at  a  time  cor- 
responding to  a  menstrual  period. 

1  "  Geburtshiilfe,"  Sth  ed.,  Bonn,  1884,  p.  405. 

2  «  Monatschr.  f.  Geburtsh.,"  xix,  S.  106. 

3  Leopold,  "  Archiv  f.  Gyn.,"  Bd.  viii,  p.  253. 
*  "Geburtshiilfe,"  Bd.  ii,  S.  3  u.  70. 

5  Gusserow,  "Archiv  f.  Gyn.,"'  Bd.  ii,  S.  218. 


176  PREGNANCY. 

The  Effect  of  Chronic  Diseases  of  the  Mother  upon  the 
Fetus. — Women  affected  with  tuberculosis,  ^  cancer,  or  chronic 
malarial  poisoning  ^  may  give  birth  to  a  succession  of  dead  chil- 
dren. Icterus  gravidarum  also,  whether  simple,  epidemic,  or 
pernicious,  might  be  a  cause  of  repeated  fetal  death,  although  the 
course  of  the  last  two  is  usually  too  rapid  to  allow  of  repeated 
impregnation. 

Nephritis. — Fehling^  has  called  attention  to  the  influence  of 
maternal  nephritis  as  a  cause  of  repeated  still -births.  The  death 
of  the  fetus  is  often  the  result  of  the  morbid  condition  of  the 
blood-vessels  in  the  maternal  portion  of  the  placenta,  corre- 
sponding to  the  condition  found  in  the  lungs,  brain,  and  other 
organs  in  chronic  nephritis.  The  brittleness  of  the  capillary 
walls  leads  to  apoplexies  and  to  the  formation  of  large  infarcts 
in  the  intercotyledonic  spaces,  which  so  compress  the  neighbor- 
ing placental  villi  that  they  can  not  perform  their  physiological 
functions.  The  effusion  of  blood  may  also  cause  a  premature 
detachment  of  the  placenta.^ 

Charpentier  and  Butte^  have  shown  that  an  excess  of  urea  in 
the  maternal  blood  may  prove  fatal  to  the  fetus  by  the  direct 
poisonous  influence  of  this  substance.  Disturbances  in  the 
maternal  blood-pressure  (Runge)  and  insufficient  oxygenation 
of  the  maternal  blood  may  also  occasionally  be  responsible  for 
the  fetal  death. 

Diabetes. — This  disease  seems  to  have  a  most  disastrous  in- 
fluence upon  the  fetus.  Matthews  Duncan ^  collected  the  record 
of  19  pregnancies  occurring  in  17  women,  in  7  of  which  the 
fetus  died  in  the  latter  part  of  pregnancy.  In  2  cases  the  children 
were  feeble  at  birth,  and  i  child  was  diabetic. 

Chronic  Poisoning. — Constantin  PauF  first  described  the  ill 
effects  of  saturnism  upon  pregnancy.  Of  123  conceptions 
observed  by  him  in  women  the  subject  of  chronic  lead-poison- 
ing, 64  ended  in  abortion,  4  in  premature  labor,  and  there  were 
5  still-births;  only  10  children  passed  the  age  of  three  years. 
These  observations  have  since  been  confirmed  by  Roque**  and 
Rennert.'^ 

J  Tarnier  et  Budin,  op.  cit.,  p.  89. 

2  Bompiani,  "  Annal.  di  Ostet.,"  vii,  42,46;  discussion  of  Dr.  Schrady's  paper, 
"Med.  News,"  1885,  i,  358;  Negri,  "Annal.  di  Ostet.,"  viii,  p.  277. 
*  "  Archiv  f.  Gyn.,"  Bd.  xxvii,  p.  300. 
4  Winter,  "  Zeit.   f.  Geburtsh.,"      Bd.  xi,  S.  398. 
^  "Trans.  Ninth  International  Medical  Congress." 
^  "  Obstet.  Trans.,"  London,  vol.  xxiv,  p.  256. 
'  Tarnier  et  Budin,  op.  cit.,  p.  31. 

8  "Th^se  de  Paris,"  1873. 

9  "Archiv  f.  Gyn.,"  Bd.  xviii,  p.  109. 


THE   DISEASES   OF   THE   FETUS.  1 77 

It  has  also  been  asserted  that  female  workers  in  tobacco  are 
pecuharly  hable  to  abortion  or  to  still-births  (Jacquemart,  Kostial), 
but  there  is  difference  of  opinion  on  the  subject.  The  late  Profes- 
sor Hunter  Maguire,  of  Richmond,  Virginia,  kindly  inquired  for 
me  of  some  of  the  largest  tobacco -manufacturers  in  that  city 
as  to  the  effect  of  tobacco  on  the  pregnant  women  in  their  employ. 
There  was  no  evidence  of  a  deleterious  influence  upon  pregnant 
women  or  their  offspring. 

Causes  of  Death  Residing  in  the  Fetus  Itself. — It  has  been 
already  stated  that  syphilitic  disease  of  the  fetus  or  ovum  is  by 
far  the  most  frequent  cause  of  habitual  death  ;  but  there  may 
be  other  causes  residing  in  the  fetus  itself  which  remain  after  the 
rigid  exclusion  of  syphilis.  It  is  well  known  that  deformities 
may  be  hereditary  in  certain  families,  carried  through  every 
member  of  several  generations.  ^  A  woman  might,  therefore, 
give  birth  to  a  number  of  children,  each  presenting  the  same 
deformity,  grave  enough  perhaps  to  destroy  life. ^  Leopold^ 
discovered  a  curious  affection  to  be  the  cause  of  death  in  several 
dead  fetuses  born  successively  of  one  woman.  This  consisted  of  a 
thickening  of  the  fibrous  and  muscular  coat  of  the  umbilical  vein  so 
that  its  caliber  was  seriously  diminished.    Syphilis  was  excluded. 

The  Causes  of  Fetal  Death  Referable  to  the  Father. — In 
case  it  is  impossible  to  attribute  the  habitual  death  of  the  fetus 
to  inherent  defects  or  to  ill-health  of  the  mother,  the  explanation 
may  be  sought  in  the  condition  of  the  father.  He  may  be  too 
old  or  too  young  to  furnish  a  fecundating  germ  of  sufficient 
vigor  to  enable  the  fetus  to  reach  maturity  ;  or  he  may  be  the 
subject  of  some  chronic  debilitating  disease,  as  nephritis,  dia- 
betes,* phthisis, '5  cancer,^  or  chronic  lead-poisoning,'^  which 
may  not  affect  the  fecundating  power  of  the  spermatic  particle, 
but  renders  it  incapable  of  performing  its  part  in  building  up 
a  healthy  embryo.  Thus,  Priestley  tells  of  a  healthy  }'oung 
woman,  whose  husband  had  albuminuria,  giving  birth  first  to  a 
sickly  infant  and   afterward   aborting   in  three   successive  preg- 

1  "British  Med.  Jour.,"  Jan.  22,  29,  1SS7  ;  "Am.  jour.  Obstet.,"  1SS6,  p. 
1 108. 

2  A  lioness  in  the  Philadelphia  Zoological  Garden  has  given  birth,  on  three  sep- 
arate occasions,  to  cubs  that  were  deformed  about  the  jaws  and  palate,  and  lived  only 
a  few  moments  after  birth.      Tliis  is  said  to  lie  the  rule  with  lionesses  in  captivity. 

3  "Archiv  f.  Gynak.,"  Bd.  x,  p.  191. 

*  Priestley,  "  Lumleian  Lectures  on  the  Pathology  of  Intra-uterine  Death,"  rep. 
from  "  British  Med.  Jour.,"  1887,  p.  8. 

5  D'Outrepont,  "  Neue  Zeit.  f.  Geburtsh.,"  1838,  Bd.  vi,  p.  34. 

6  Jacquemier,  "Diet.  Encyc.  des  Sc.  med.,"  art.  "  Avortement,"  vol.  vii, 
P-  537- 

'  Constantin  Paul,  loc.  cit. 
12 


1/8  PREGNANCY. 

nancies,  or  until  her  husband  succumbed  to  uremia.  D'Outre- 
pont  also  has  related  the  following  case  :  A  woman  married  to 
a  phthisical  man  became  pregnant  five  times,  in  each  instance 
giving  birth  to  a  dead  child  at  the  eighth  month.  Remarried  to 
a  healthy  husband,  she  gave  birth  to  four  healthy  infants  in 
succession.  Paul,  in  39  pregnancies  in  7  women  whose 
husbands  were  afflicted  with  saturnism,  observed  1 1  abortions 
and  I  still-born  child,  while  of  the  27  children  born  alive  only 
9  survived  early  infancy. 

The  Habit  of  Giving  Birth  to  StilUborn  Children. — If 
all  the  causes  in  the  mother  that  have  been  enumerated  as  respon- 
sible for  the  death  of  the  fetus  are  excluded,  if  there  is  no  sign 
of  abnorm^ality  or  disease  in  the  fetus  or  ovum,  or  if  there  is 
nothing  in  the  condition  of  the  father  to  account  for  the  repeated 
still-births,  their  occurrence  may  be  attributed  to  a  habit  of  the 
mother  of  giving  birth  to  dead  children.  Such  cases  are  extremely 
rare,  as  may  be  imagined,  but  are  by  no  means  unknown.  Two 
examples  may  be  cited:  A  woman  ^  subjected  to  a  severe  fright 
in  the  last  month  of  pregnancy  afterward  gave  birth  to  a  dead 
child.  In  twelve  successive  pregnancies  she  gave  birth  to  dead 
children  at  the  seventh  month.  The  mother  of  Hohl  ^  gave  birth 
alternately  to  living  and  dead  children.  The  first  child  was 
living  and  healthy,  the  second  dead,  and  so  on  until  the  tenth 
pregnancy,  when  so  certain  was  everyone  that  the  child  would  be 
born  dead  that  nothing  was  provided  for  it.  It  was  born  alive, 
however,  and  was  Hohl  himself. 

The  Diagnosis  of  the  Cause  of  Repeated  Stillbirths. — The  suspi- 
cion of  syphilis  in  the  parents  usually  first  enters  the  mind 
of  a  practitioner  who  meets  with  cases  of  habitual  death  of  the 
fetus  ;  but,  aside  from  the  possible  injustice  of  such  a  suspicion^ 
it  may  suggest  inappropriate  treatment.  It  is,  therefore,  im- 
portant to  discover  the  true  cause  of  the  inability  of  the  woman 
to  bear  a  living  child,  for  the  preventive  treatment  of  the  still- 
births must  differ  radically  with  each  of  the  many  causes  that  have 
been  enumerated  above.  SyphiHs,  as,  by  far  the  most  frequent 
cause  of  habitual  death  of  the  fetus,  must  be  first  excluded  before 
another  cause  is  sought.  But  this  is  not  always  easy.  It  fre- 
quently happens  that  the  history  of  the  parents  is  obscure,  and  that 
the  fetus  is  expelled  already  macerated  or  with  no  distinctive 
marks  of  disease  upon  its  body.  In  such  a  case  a  careful  exami- 
nation of  the  fetal  body  and  of  its  appendages  usually  reveals  un- 
mistakable evidence  of  the  existence  of  syphiHs. 

1  Hayes,  London  "Lancet,"  1874,  vol.  ii. 
■^  Tarnier  et  Budin,  op.  cii.,  p.  365. 


THE  DISEASES   OF   THE   FETUS.  1 79 

To  determine  the  other  causes  of  repeated  fetal  death,  endo- 
metritis and  metritis  should  be  looked  for.  An  anomalous 
condition  of  the  uterus  may  be  discovered.  The  blood  of  the 
mother  should  be  examined  for  anemia.  The  lungs  should  be 
examined  for  phthisis,  and  the  urine  for  sugar  or  for  albumin  and 
casts.  The  history  of  the  patient  may  point  to  the  existence 
of  malaria  or  of  chronic  lead-  or  tobacco-poisoning.  Physical 
signs  may  denote  a  cancer,  or  there  may  be  unmistakable  jaundice. 
The  fetus  itself  must  be  examined  for  some  hereditary  defect, 
and  the  cord  for  stenosis  of  the  umbilical  vein.  Finally,  the  con- 
dition of  the  father  must  be  inquired  into.  If  all  other  signs  fail, 
the  diagnosis  must  rest  upon  a  habit  or  upon  a  hereditary  pre- 
disposition of  the  mother. 

The  Preventive  Treatment  of  Habitual  Death  of  the  Fetus. — 
In  the  case  of  syphilis  of  the  parents  an  appropriate  antisyphilitic 
treatment  should  be  administered.  So  frequently  is  an  antisyphi- 
litic treatment  successful  in  these  cases  that  certain  writers  have 
recommended  the  administration  of  potassium  iodid  or  mercury 
to  every  woman  who  was  in  the  habit  of  giving  birth  to  dead 
children.  If  a  woman  first  comes  under  observation  after  im- 
pregnation has  occurred,  mercury  and  iodid  of  potassium  should 
be  administered  throughout  the  whole  of  pregnancy  if  there  is 
reason  to  suspect  that  the  fetus  may  be  syphilitic. 

If  there  should  be  a  chronic  endometritis,  a  curettage  may 
be  followed  by  conception  and  a  normal  pregnancy.  ^  A  cor- 
rection of  a  displacement  of  the  uterus  or  a  repair  of  a  lacerated 
cervix  may  be  followed  by  the  same  result.  In  anemic  women 
a  tonic  treatment  is  often  followed  by  the  birth  of  a  vigorous 
infant.  Plethoric  patients,  on  the  other  hand,  would  be  bene- 
fited by  increased  exercise,  by  frequent  depletion,  and  by  a 
restricted  diet.  Phthisis,  cancer,  diabetes,  or  nephritis  in  the 
mother  renders  the  prognosis  for  the  fetus  grave.  In  chronic 
malarial,  lead-,  or  tobacco-poisoning  the  elimination  of  the  poison 
should  enable  the  woman  to  bear  a  living,  liealthy  child. 

The  father's  health,  if  impaired,  should  be  improved,  if  pos- 
sible. 

There  are  women  who  carry  a  living  child  up  to  a  certain 
period  of  pregnancy,  but  if  allowed  to  go  to  term  give  birth  re- 
peatedly to  dead  infants.  Thus,  in  Tarnier's^  case,  a  woman, 
apparently  in  good  health,  gave  birth  to  thirteen  dead  chiklren 
successively,  although  it  was  demonstrated  that  the  fetus  was  in 
each  instance  alive  until  the  last  month  of  pregnancy.     The  same 

1  Schroeder,  "  Geburtsh.,"  8th  ed.,  p.  405. 

2  Loc.  ciL,  p.  T,(>'^. 


l8o  PREGNANCY. 

authority  cites  another  instance  of  a  woman  who  in  seven  suc- 
cessive pregnancies  experienced  the  active  movements  of  her  child 
until  within  fifteen  days  of  the  normal  time  of  delivery,  and  yet 
always  gave  birth  to  a  dead  infant.  In  such  cases  the  birth  of  a 
living  child  could  be  secured  by  inducing  labor  at  a  time  before 
the  period  of  pregnancy  at  which  the  accustomed  death  of  the 
fetus  occurred. 


CHAPTER   VI. 
The  Physiology  of  Pregnancy. 

The  whole  organism  shows  alterations  in  sympathy  wdth  the 
development  of  the  pregnant  uterus ;  but,  as  might  be  expected, 
these  alterations  are  m.ost  striking  in  the  genital  region. 

The  uterus  exhibits  an  extraordinary  development  in  all 
its  constituent  parts.  The  muscle- f hers  hypertrophy  until  they 
are  eleven  times  as  long  and  five  times  as  broad  as  those  of  the 
non-pregnant  uterus,  h.  multiplication  of  the  fibers,  a  true 
hyperplasia,  occurs  to  a  limited  extent  in  the  first  three  months. 
The  elastic  tissue  develops  with  the  growth  of  its  muscle  fibers. 
The  connective  tissue  increases  markedly,  sending  in  newly  devel- 
oped fibers  between  the  muscle-bundles  and  increasing  in  bulk 
by  a  serous  infiltration.  The  peritoneal  covering  of  the  womb  shows 
a  true  hyperplasia  to  enable  it  to  keep  pace  with  the  growth  of  the 
uterus.  The  development  of -new  cells  is  not  entirely  uniform,  so 
that  the  peritoneum  covering  the  womb  varies  in  thickness.  The 
membrane  is  quite  firmly  adherent  to  the  uterus  except  over  the 
lower  uterine  segment,  where  it  is  readily  stripped  off".  The 
blood-vessels  develop  rapidly.  The  arteries  are  vastly  increased 
in  caliber  and  length  and  become  extremely  tortuous.  The 
uterine  artery  sends  a  large  branch  to  the  upper  margin  of  the 
lower  uterine  segment,  and  numerous  smaller  branches  penetrate 
the  uterine  wall,  where  in  some  situations  they  communicate 
directly  with  the  veins.  At  the  placental  site  the  arteries  termi- 
nate in  the  curling  arteries  of  the  uterine  decidua,  emptying 
directly  into  the  placental  lacunae,  where  the  blood  bathes  the 
placental  villi  projecting  into  them.  The  uterine  body  may  be 
regarded  from  one  point  of  view  as  a  huge  venous  plexus.  The 
walls  of  the  veins  are  reduced  to  the  intima,  and  running  between 


THE   PHYSIOLOGY  OF  PREGNANCY. 


I8l 


muscle-bundles,  the  contraction  of  the  uterine  muscle  after  labor 
obliterates  them. 

The  nerves  are  increased  more  by  a  development  of  the  con- 
nective tissue  about  them  (neurilemma)  than  by  an  increase  of 
the  nerve-elements  ;  but  there  is  some  new  development  of  nerve- 
tissue,  the  filaments  extending  toward  the  uterine  cavity.  The 
main  supply  of  the  womb  is  from  the  sympathetic  system.  The 
ganglia  in  the  genital  region  show  hypertrophy,  especially  the 
cervical. 

The  lynipliatics  are  increased  by  hypertrophy  and  by  hyper- 
plasia.     The  lymph-spaces  below  the  uterine  mucous  membrane 


Fig.   123 A,  Isolated  muscle-elements  of  the  non-pregnant  uterus  ;   B,  cells  from 

the  organ  shortly  after  delivery  (Sappey). 

are  enormously  enlarged,  and  the  lymph-tubes  leading  from  them 
through  the  uterine  muscles  reach  the  size  of  a  goose-quill. 
These  lymph-tubes  or  vessels  are  collected  in  a  plexus  beneath 
the  peritoneum. 

This  arrangement  and  development  of  the  lymphatics  explain 
in  part  the  remarkably  rapid  absorption  of  a  great  portion  of  the 
uterus  after  labor,  and  account  for  the  invasion  of  infectious 
bacteria;  with  peritonitis  oftentimes  as  an  early  symptom,  from 
the  easy  communication  between  the  submucous  and  the  sul)- 
peritoneal  lymph- spaces. 

Anatomy  of  the  Uterus  at  Full  Term. — The  muscle-fibers  of 
the  non-pregnant  uterus  have  a  very  irregular  arrangement.     In 


1 82 


FREGXAXCY. 


Closely 
iniej'woven 
layers. 


Limit  of 
fir7nly  ad- 
herent peri- 
toneum. 


I 


Retraction-ring, 


the  pregnant  womb  late  in  gestation  three  layers  may  be  distin- 
guished :  An  outer,  a  middle,  and  an  internal  layer.  The  outer  is 
continuous  with  the  muscular  fibers  in  the  round  ligaments  and 
tubes,  and  is  mainly  longitudinal  in  arrangement.  The  middle 
layer  is  composed  of  bundles  which  pass  from  their  peritoneal 

attachment  obliquely  downward 
and  inward  to  be  attached  to  the 
submucous  tissue.  Above  the 
"contraction  ring,"  or  "ring  of 
Bandl," — the  upper  boundary  of 
the  lower  uterine  segment, — the 
oblique  arrangement  is  less 
marked,  while  below  it  is  more 
pronounced.  The  internal  layer 
is  thin  and  poorly  developed,  ex- 
cept around  the  orifices  of  the 
womb.  Its  arrangement  is  chiefly 
circular,  and  it  is  most  strongly 
developed  at  the  openings  of  the 
tubes  and  at  the  internal  os. 

Changes  in  Volume,  Capacity, 
and  Weight. — Before  impregna- 
tion the  length  of  the  uterine 
cavit}^  is  about  6.^^  cm.  (2^  in.); 
at  term  it  is  increased  to  30. 5  cm. 
(12  in.),  while  its  breadth  is  22.9 
cm.  (9  in. J  and  its  depth  20.32  cm. 
(8  in.).  The  capacity  changes 
from  little  more  than  16.5  c.c.  (i 
cu.  in.)  to  more  than  6600  c.c. 
(400  cu.  in.),  and  its  weight  in- 
creases from  about  28.35  g"^-  (^ 
ounce)  to  the  neighborhood  of 
907.2  gm.  (2  pounds). 

Changes  in  Form,  Position,  Di= 
rection,  and  Topographical  Rela= 
tions. — At  first  the  uterus  is 
changed  from  a  flattened,  pyri- 
form  body  to  a  spherical  or  fig- 
shape,  and  after  the  fourth  month 
to  an  ovoid.  During  the  early 
months  the  uterus  descends  into  the  peh'ic  cavit}^,  as  a  result 
of  its  increased  weight.  After  the  third  month  it  rises  steadily 
until  the  fundus  reaches  the  epigastrium  in-  the  ninth  month,  but 
before  term  (four  weeks  in  primiparre,  ten  days  or  one  week  in 


Easily 
separable 
layers. 


I 

i 


Internal  os. 


External  os. 

Vagina} 

Fig.  124. — Section  of  the  wall  of 
the  pregnant  uterus.  The  difference 
in  texture  between  cervix  and  lower 
uterine  segment,  according  to  Hofmeier, 
is  clearly  shown,  as  well  as  the  loose- 
meshed  and  close-meshed  muscle- 
layers  of  the  upper  and  lower  uterine 
segments  ( Hofmeier j. 


THE   PHYSIOLOGY  OF  PREGNANCY. 


183 


multiparae)  the  fundus  sinks  again,  as  the  presenting  part  and  lower 
uterine  segment  become  engaged  in  the  pelvic  cavity.  This  phe- 
nomenon is  explained  by  contraction  of  the  overstretched  ab- 
dominal walls  and  a  consequent  diminution  in  the  area  of  intra- 
abdominal space,  the  uterus  and  its  contents  being  displaced  in 
the  direction  of  least  resistance,  namely,  downward  through  the 
superior  strait,  into  the  pelvic  cavity.  During  the  first  three 
months  the  womb  exhibits  a  sharp  anteflexion,  due  to  the  in- 
creased weight  of  the  body  and  the  decreased  tonicity  of  the 
lower  uterine  segment. 


Fig.  125. — The  relation  of  the  pregnant  uterus  at  term  to  the  intestines. 

After  the  third  month,  as  the  womb  rises  into  the  abdominal 
cavity,  the  laxity  of  the  abdominal  wall  allows  it  to  fall  some- 
what forward,  so  that  the  anteflexion  persists  to  a  certain  degree, 
but  diminishes  as  the  womb  increases  in  length.  In  consequence 
of  the  position  of  the  sigmoid  flexure  and  rectum,  almost  always 
distended  in  constipated  women,  the  uterus  is  tilted  to  the  right 
side  and  is  rotated  on  its  longitudinal  axis,  so  that  the  anterior 
surface  looks  toward  the  right,  and  the  left  broad  ligament,  with 
its  attached  structures,  becomes  more  accessible  to  abdominal  pal- 


1 84 


PREGNANCY. 


pation.  The  topographical  relation  of  the  intestines  is  impor- 
tant. They  should  always  be  situated  above  and  behind  the 
uterus,  thus  giving  no  resonance  over  the  anterior  abdominal  wall 
on  percussion;    but  in  rare  cases  of  exaggerated  tympany  the 


Fig.  126. — The  cervix  in  tiie  fiftli  month 
of  pregnancy  (Leopold). 


Fig.    127. — The  cervix  in  the  seventh 
montli  of  pregnancy  (Leopold) . 


intestines  prolapse    in   front    of   the    womb,    giving  a  resonant 

note    on    percussion    all 
/  "i      °^^^  ^^  abdomen. 

Alterations  in  the  Cer= 
vix. — The  cervix  is  soft- 
ened and  somewhat  hy- 
pertrophied  during  the 
first  four  months,  but 
its  canal  is  undilated 
until  the  first  stage  of 
labor  begins.  Through- 
out the  whole  duration 
of  pregnancy  the  canal 
remains  unaltered  in 
length.  The  mucous 
glands  of  the  cervix  se- 
crete a  peculiarly  tough 

mucus   (mucous  plug),  which   stops  up  the  cervix   like  a  cork 

during  pregnancy. 


Fig.   12S. — The  cervix  in  the  ninth  month  of 
pregnancy  (Leopold). 


PLATE  6, 


The  difference  in  tlie  blood-vessel  develo])ment  in  the  bladder  wall  in  a  preg- 
nant woman  (A)  and  a  non-pret^nant  woman  (B),  both  cystoscopic  views  being  taken 
around  the  right  ureter  with  a  water-distentioa   instrument  (I''.  Tilden  Brown). 


CHANGES  IN  THE   SEVERAL    SYSTEMS   OF   THE   BODY.    185 

Alterations  in  Vagina  and  Vulva, — The  changes  in  these  regions 
are  due  mainly  to  an  increased  blood-supply,  as  noticed  in 
enumerating  the  signs  of  pregnancy.  Thus  are  explained  the 
darkened  color  of  the  mucous  membrane,  the  increased  secretion, 
and  the  development  in  the  muscular  and  mucous  walls. 

The  pelvic  joints  are  loosened  and  there  is  an  increase  in  the 
motility  of  the  pelvic  bones,  with  the  purpose  of  facilitating  the 
passage  of  the  fetal  body  in  labor. 

The  abdominal  walls  show  a  stretching  of  all  the  con- 
stituent parts,  with  the  formation  of  white,  bluish,  or  reddish 
striae,  due  to  thinning  and  disorder  of  the  arrangement  of 
the  connective-tissue  layer  of  the  skin,  with  atrophic  changes. 
If  this  stretching  of  the  skin  is  painful,  partial  relief  is  afforded  by 
inunctions  with  cacao-butter,  sweet-oil,  lanolin,  or  vaselin,  to  in- 
crease its  pliability.  The  recti  muscles  separate  as  the  abdo- 
men distends,  and  pain  may  be  experienced  in  the  attachments 
of  the  abdominal  muscles  to  the  ribs  and  to  the  pelvis.  There 
is  a  marked  deposition  of  fat  in  the  abdominal  walls,  sometimes 
as  early  as  the  second  month,  giving  the  woman  a  much  fuller 
figure  than  could  be  accounted  for  by  the  size  of  the  pregnant 
uterus.^ 

The  Bladder  and  Rectum. — The  growth  of  the  pregnant 
uterus  mechanically  interferes  with  the  functions  of  these  viscera, 
hence  irritability  of  the  bladder  and  constipation  are  the  rule  in 
pregnancy.  By  mechanical  interference  with  the  blood-supply, 
in  addition  to  the  congestion  of  the  pelvis,  hemorrhoids  of  the 
anus  and  rectum  are  common.  Varices  of  the  bladder,  too,  may 
develop,  rarely  giving  rise  to  hematuria. 

CHANGES  IN  THE  SEVERAL  SYSTEMS  OF  THE  BODY. 
GENERAL  CHANGES. 

Circulatory  System, — The  whole  quantity  of  the  blood   is 

increased,  but  not  equally  in  all  its  constituent  parts.  The  water 
and  fibrin-making  elements  are  most  markedly  increased  ;  the  red 
corpuscles  and  hemoglobin,  while  actually  somewhat  increased, 
are  relatively  diminished ;  the  white  corpuscles  are  actual h'  antl  rel- 
atively increased.  There  is  therefore  a  physiologic  leukocytosis, 
a  hydremia,  and  an  anemia.-  The  percentage  of  lymphocytes, 
polymorphonuclear  cells,and  eosinophiles  appears  to  be  unaltered.  ^ 

1  The  reader  no  doubt  remembers  that  Roderick  Random's  Narcissa  "had 
grown  qualmish  of  late  and  remarkalily  round  in  the  waist,"  when  she  was  proliably 
not  more  than  six  or  eight  weeks  pregnant. 

2  Vox  a  good  bibliography  see  Olshausen  and  Veit,  "Geburtshiilfe,"'  5tli  edition, 
1902,  p.  105.  -^  G.  R.  Pray,  "American  Gynecology,"  October,  1902. 


l86  PREGNANCY. 

During  labor  there  is  a  distinct  increase  in  the  leukocytes,  a 
disappearance  of  the  eosinophiles,  and  an  augmentation  of  the 
red  blood-corpuscles.  After  labor  the  constitution  of  the  blood 
returns  rapidly  to  the  normal/ 

Recent  investigations  of  the  mutual  relations  of  blood-serum 
and  syncytium  bid  fair  to  solve  some  of  the  problems  of  fetal 
nutrition  and  maternal  toxemia.  It  appears  that  the  syncytial 
cells  produce  a  hemolytic  and  the  blood-serum  a  syncytiolytic 
agent.  The  former  sets  free  albuminous  substances  in  the  blood 
designed  probably  for  the  nutrition  of  the  fetus;  the  latter  keeps 
in  restraint  the  exuberant  growth  of  syncytium  and  by  the  solution 
of  the  cells  probably  frees  substances  which  influence  both  the 
maternal  and  fetal  organism.  If  the  balance  between  hemolysis 
and  syncytiolysis  is  disturbed,  it  is  probable  that  the  maternal 
organism  is  adversely  affected  and  that  the  toxemia  of  early 
pregnancy  is  a  result.^ 

The  left  side  of  the  heart  is  said  to  hypertrophy,  so  that  its 
walls  are  increased  in  thickness  about  twenty-five  per  cent.,  and  its 
weight  increases  appreciably;  but  Gerhardt  showed  that  the  sup- 
posed enlargement  of  cardiac  dullness  on  percussion  was  due  to 
displacement  of  the  heart,  and  Lohlein  was  unable  to  find  increased 
weight  in  a  number  of  specimens.^  Stengel  and  Stanton,  in  a 
study  of  70  cases  in  the  maternity  of  the  University  of  Pennsylvania, 
found  that  there  was  no  increase  of  blood  pressure  and  no  ad- 
ditional work  for  the  heart  to  do  in  pregnancy ;  also  that  there  was 
no  hypertrophy  of  the  left  ventricle.*  In  consequence,  it  is  claimed, 
of  unusual  determination  of  blood  to  the  brain  there  are  developed, 
in  about  one-half  of  the  cases  of  pregnancy,  on  the  inner  table  of 
the  skull,  new  formations  of  bone,  called  by  Rokitansky  osteo- 
phytes. It  has  been  claimed  that  the  pulse  of  a  pregnant  woman 
does  not  undergo  the  usual  acceleration  when  the  patient 
changes  from  a  horizontal  to  an  erect  posture  (Jorisenne's  sign  of 
pregnancy).  This  symptom,  however,  is  of  no  value.  The  heart 
of  the  pregnant  woman  shares  in  the  nervous  irritability  of  the 
whole  organism,  and  she  is  liable  to   "  cardiac  nerve-storms." 

The  urine  in  pregnancy  is  increased  in  quantity,  and  becomes 
more  watery,  having  a  specific  gravity  of  about  1014;  the  urea 
excretion  as  estimated  by  such  an  apparatus  as  Doremus's  ure- 
ometer  is  usually  below  normal  and  is  very  variable.  The  propor- 
tion of  other  nitrogenous  substances  in  the  urine,  ammonia  and 
kreatinin,  is  increased,  the  percentage  of  urea  nitrogen  is  decreased, 

^Paul  Gorton,  "Modification  du  Sang  pendant  I'accouchement  et  les  suites  de 
Couches  normales  et  pathologiques  "  ;  "  Ann.  de  Gyn.,"  Sept.,  1903. 

^Scholten  and  Veit,  "  Syncytiolyse  u.  Haemolyse,"  '*  Ztchr.  f.  Geb.  u.  Gyn.," 
Bd.  xlix.  '  "  Miiller's  Handbuch,"  vol.  i. 

^  "  The  Heart  and  Circulation  in  Pregnancy  and  the  Puerperium,"  Stengel  and 
Stanton,  "  U.  of  P.  Med.  Bull.,"  September,  1904. 


CHANGES  IN  THE   SEVERAL    SYSTEMS   OF   THE   BODY.    1 87 

and  the  total  output  of  nitrogen  is  lower  than  normal.  The 
other  solids  are  about  normal.  It  has  been  claimed  that  the  urine 
of  pregnant  women  in  the  last  three  months  of  gestation  contains 
double  and  treble  the  usual  amount  of  urobilin,  showing  the  extra 
work  thrown  upon  the  excretory  organs — both  liver  and  kidneys.' 
Acetonuria  is  present  in  about  a  third  of  pregnant  women,  but 
has  no  special  significance. 

The  digestive  tract  is  alm.ost  constantly  disturbed  in  preg- 
nancy. Nausea  and  vomiting,  beginning  at  about  the  sixth  week 
and  lasting  to  the  third  month,  are  so  common  as  to  be  diagnostic 
signs  of  great  value.  These  manifestations  are  usually  worse  on 
first  arising  from  bed  in  the  morning  (morning  sickness),  and  are 
explained  either  by  a  reflex  irritation  of  the  sympathetic  nervous 
system  due  to  the  expansion  of  the  uterus  or  by  a  toxemia.  The 
assumption  of  the  erect  position  suddenly  increases  the  congestion 
of  the  uterus  and  aggravates  its  irritability.  Torpor  of  the  intes- 
tines and  of  the  rectum,  induced  by  pressure  of  the  growing  womb 
on  the  abdominal  contents,  is  the  cause  ordinarily  of  obstinate 
constipation. 

The  nervous  system  show^s  remarkable  changes  in  conse- 
quence of  pregnancy.  These  are  alterations  in  disposition,  per- 
versions of  taste  (longings),  a  disposition  to  melancholia,  and 
possibly  severe  neuralgias,  especially  of  the  face  and  teeth. 

The  thyroid  gland  hypertrophies  in  about  80  per  cent,  of  preg- 
nant women.  As  it  has  been  observed  that  in  a  large  proportion  of 
those  in  whom  this  hypertrophy  fails  to  occur,  albuminuria  appears, 
Nicholson  and  others  attribute  to  the  thyroid  secretion  an  antidotal 
effect  upon  the  toxins  of  later  pregnancy. 

Changes  in  weight  must  be  expected  in  consequence  of 
seven  pounds  of  baby,  one  pound  of  liquor  amnii,  a  pound  of  pla- 
centa, and  two  pounds  of  uterus  which  are  to  be  found  in  a  preg- 
nant woman  at  term,  not  to  mention  the  increased  deposition  of 
fat  all  over  the  body  and  the  additional  quantity  of  blood  formed 
in  pregnancy.  An  increase  of  -^  part  of  the  original  body- 
weight  may  be  expected  on  the  average,  according  to  Gassner. 
This  estimate,  however,  is  not  uniformly  correct,  as  exceptions 
are  frequently  observed.  In  a  series  of  cases  which  I  investi- 
gated in  the  Maternity  Hospital  there  was  an  extreme  variation  of 
from  one  to  forty  pounds  in  the  gain  of  weight  in  pregnant  women. 

The  changes  in  the  respiratory  apparatus  are  not  of 
great  importance.  The  lungs  arc  shorter  but  broader,  leaving 
the  capacity  little  altered.  Examination  of  the  expired  air  has 
shown  an  increased  activity  of  the  lungs  in  the  excretion  of  the 

'  C.  Merletti,  "  Urobilinurie  bei  Schwangeren  u.  Vermehrung  derselben  in 
Fallen  endouterinen  Fruchttodes,"  *'Centralbl.  f.  Gyn.,"  No.  16,  1902. 


1 88  PREGNANCY. 

products  of  life  processes,  the  lungs  sharing  the  work  of  the  other 
excrementory  organs  in  disposing  of  the  surplus  effete  products 
from  mother  and  fetus. 

Prolongation  of  Pregnancy  and  Missed  Labor Pregnancy 

is  quite  frequently  prolonged  to  310  days.^  It  may  have  a  dura- 
tion of  320  days,  or  40  days  above  the  average;  and  there  are 
cases  on  record,  though  somewhat  apocryphal,  of  even  longer 
duration.^  In  about  six  per  cent,  of  pregnant  women  the  duration 
of  pregnancy  is  over  300  days.  The  result  in  labor  may  be  most 
serious  in  consequence  of  overgrowth  of  the  fetus.  Some  of  the 
worst  cases  of  obstructed  labor  are  due  to  this  cause.  It  is  a  good 
rule  of  practice,  therefore,  never  to  allow  any  woman  to  go  more 
than  two  weeks  beyond  term. 

Missed  labor  means  the  occurrence  of  a  few  labor-pains  at 
term,  their  subsidence,  and  the  retention  of  the  product  of  con- 
ception for  a  varying  period  thereafter.  "Missed  labor"  usually 
turns  out  to  be  extra-uterine  pregnancy  or  pregnancy  in  one 
horn  of  a  uterus  bicornis;  it  may  be  due,  however,  to  obstructed 
cervix  from  cancer,  conglutination,  a  tumor,  or  excessive  rigidity. 

The  Management  of  Normal  Pregnancy. — Too  frequently 
the  physician  gives  his  pregnant  patients  no  attention,  assuming 
that  their  condition  is  physiological  and  that  they  are  in  good 
health  till  they  fall  in  labor.  No  view  could  be  more  erroneous. 
The  border-line  betw^een  health  and  disease  is  so  easily  passed 
in  pregnancy  that  the  most  serious  compUcations  may  acquire 
irresistible  headway,  undetected,  unless  the  patient  is  ad- 
vised carefully  and  constantly  watched  during  the  whole  of 
her  gestation.  Constipation  must  be  corrected.  The  urine 
should  be  examined  once  in  two  weeks  during  the  whole  dura- 
tion of  pregnancy  until  the  last  month,  when  the  examinations 
should  be  made  once  a  week.  The  routine  examination  for 
specific  gravity,  reaction,  albumin,  and  sugar  is  sufficient  in  the 
average  case.  If  any  sign  appears,  indicating  abnormality  of 
kidney  action,  a  more  careful  examination  should  be  made,  in- 
cluding total  quantity,  nitrogen  elimination  in  its  different  form.s, 
microscopic  elements,  etc.;  which  can  best  be  done  by  an  expert 
in  urinalysis.  The  patient  should  be  cautioned  to  reduce  her 
physical  exercise  below  what  she  is  ordinarily  accustomed  to,  and 
always  to  stop  short  of  fatigue,  avoiding  particularly  any  sudden 
jolt  or  jar  or  any  of  the  movements  that  strain  the  abdomen  and 
increase  intra-abdominal  pressure,  such  as  lifting  a  weight  down 

1  A  very  extensive  bibliography  of  prolonged  pregnancy  may  be  found  in  the 
twenty  volumes  of  the  "  Jahresbericht  uber  d.  Fortschr.  a.  d.  Gebiet.  d.  Gyn.  u. 
Geburtsh." 

^  A  child  was  presented  at  a  meeting  of  the  Munich  Gynecological  Society  in 
.1902,  l)orn  339  days  after  the  last  menstruation.  "  Monatsh.  f.  Geb.  u.  Gyn.," 
January,  1903. 


THE   DIAGNOSIS   OF  PREGNANCY.  189 

from  a  height  (a  closet-shelf)  or  raising  from  the  ground  a  heavy 
weight. 

The  diet  must  be  regulated  so  that  the  kidneys  shall  not  be 
overtaxed.  Meat  should  be  eaten  but  once  a  day,  red  meat 
only  four  times  a  week,  and  a  ravenous  appetite,  which  sometimes 
appears  in  pregnancy,  must  not  be  fully  gratified.  Three  simple 
meals  a  day  with  no  nutritious  food  between  meals  should  be  the 
rule.     Otherwise  the  fetus  may  reach  an  abnormal  size.^ 

The  patient  must  be  cautioned  against  exposure  to  cold  and 
wet ;  one  such  exposure  or  sitting  in  a  draft  after  being 
overheated  has  frequently  determined  an  acute  nephritis,  with 
fatal  results  to  both  mother  and  child.  Tonic  remedies  are  some- 
times called  for  if  the  hydremia  of  pregnancy  is  exaggerated  or 
if  there  is  not  a  normal  gain  in  weight.  The  syrup  of  the  lacto- 
phosphate  of  lime  is  administered  with  advantage  to  stay  the 
ravages  in  the  teeth  of  pregnant  women,  and  with  this  remedy 
internally  should  always  be  prescribed  a  mouth-wash  of  milk  of 
magnesia  to  correct  the  acidity  of  secretions  and  to  arrest  the 
development  of  leptothrix  buccalis,  which,  in  the  opinion  of 
dental  surgeons,  are  more  detrimental  to  the  teeth  than  the  drain 
on  the  system  for  bone  salts  to  build  up  the  fetal  skeleton. 
Strychnin  in  the  later  months  is  claimed  to  influence  labor  benefi- 
cially and  to  favor  puerperal  involution.  This  I  believe  to  be 
correct.  The  nipples  should  be  prepared  for  their  future  function 
by  applications  of  glycerol  of  tannin  and  water,  equal  parts,  twice 
a  day  for  four  weeks  preceding  confinement. 

THE  DIAGNOSIS  OF  PREGNANCY. 

It  might  seem  to  the  inexperienced  that  the  recognition  of 
pregnancy  is  easy.  Every  physician  has  ample  opportunity 
to  familiarize  himself  with  its  signs,  and  these  signs  are  gross 
and  easily  appreciable,  at  least  in  the  later  months.  But  in 
reality  there  is  scarcely  a  common  condition  in  the  human  body 
that  is  so  often  overlooked  or  mistaken  for  something  else,  and 
there  are  no  mistakes  in  diagnosis  so  detrimental  to  a  physician's 
reputation,  or  sometimes  so  fatal  to  the  patient,  as  mistakes  in  the 
diagnosis  of  pregnancy.  To  cite  as  illustrations  only  cases  of 
which  the  author  has  personal  knowledge :  A  physician  per- 
formed what   he   believed   would   be   a  Cesarean  section  on  a 

1  To  reduce  the  size  of  the  child  in  cases  of  moderately  contracted  pelves,  Pro- 
chownick  ("Centralbl.  f.  Gyn.,"  No.  33,  1889)  proposed  a  diet  of  nitrogenous  food 
and  the  least  possiljle  amount  of  lluids,  beginning  in  the  seventli  month.  Preiile 
(•'Obstetrics,"  May,  1S99)  collected  47  cases  managed  by  this  plan  with  apparently 
gratifying  success. 


190  PREGNANCY. 

rachitic  dwarf,  thought  to  be  in  labor  at  term.  Several  other 
physicians  examined  the  patient  before  the  operation,  and  all 
agreed  that  she  was  pregnant  and  in  labor.  There  was  nothing 
in  her  abdomen  but  the  usual  contents  and  a  huge  mass  of 
omental  fat.      It  was  a  case  of  pseudocyesis. 

A  gynecologist  on  the  staff  of  a  large  hospital  has  twice 
operated  for  fibroid  tumors  of  the  womb,  and  only  after  the  am- 
putation of  the  uterus  found  that  it  was  pregnant,  and  not  the 
seat  of  a  fibroid  tumor  at  all.  Both  patients  died.  In  a  public 
cHnic,  before  a  large  audience,  a  gynecologist  removed  what  he 
called  a  myoma.  The  tumor  was  cut  open  immediately  and  all 
the  spectators  had  the  opportunity  of  seeing  a  pregnant  uterus 
with  a  fetus  in  it.  There  was  no  myoma.  The  woman  died. 
Another  specialist  in  a  large  hospital  operated  for  ovarian  cyst. 
He  punctured  the  "cyst"  after  opening  the  abdomen,  and  found 
a  pregnant  uterus  with  hydramnios.  An  entirely  unnecessary 
hysterectomy  was  performed. 

An  obstetrician  on  the  staff  of  another  hospital  attempted  to 
induce  labor  on  a  patient  in  the  last  stages  of  phthisis  who  evi- 
dently would  not  live  till  term.  The  bougie,  however,  could 
not  be  inserted  more  than  2  ^  inches.  On  the  following  day  the 
patient  died.  In  anticipation  of  her  death,  all  the  arrangements 
had  been  made  for  a  postmortem  Cesarean  section  the  moment 
she  expired.  The  operation  was  performed  before  a  large  audi- 
ence. The  abdominal  tumor  proved  to  be  an  ovarian  cyst,  and 
not  a  pregnant  uterus.  A  woman  was  admitted  to  the  medical 
wards  of  a  hospital  with  what  was  thought  to  be  a  cancer  of 
the  stomach.  Gastric  lavage  was  energetically  carried  out  with 
unlooked-for  success  ;  in  several  weeks  all  gastric  symptoms 
ceased.  At  the  same  time  an  abdominal  tumor  was  observed, 
which,  on  examination,  proved  to  be  a  pregnant  uterus.  The 
patient  had  been  suffering  from  the  vomiting  of  pregnancy.  A 
young  unmarried  girl  of  good  family  was  about  to  be  operated 
upon  for  a  splenic  tumor  when  it  was  discovered  that  the  tumor 
was  a  pregnant  womb  much  displaced  and  distorted  by  tight 
lacing.  A  woman  was  sent  to  the  author  from  a  distant  State  for 
operation  on  account  of  a  large  fibroid  tumor  of  the  uterus  ;  she 
was  pregnant  with  twins,  had  no  fibroid,  and  was  easily  deliv- 
ered. A  young  girl  was  referred  to  the  author  for  the  removal 
of  an  ovarian  cyst ;  her  physician  stated  that  the  eminent  re- 
spectability of  the  girl  precluded  the  idea  of  pregnancy.  Re- 
spectability had  proved  no  bar  to  the  penetration  of  a  sperma- 
tozoon.     She  was  pregnant  at  term. 

The  author  once  examined  in  consultation  a  woman  who  was 
supposed  to  be  pregnant  twelve   months.      Her  physician  and 


THE  DIAGNOSIS   OF  PREGXANCY.  I9I 

nurse  had  been  engaged  and  every  other  preparation  made 
for  the  expected  childbirth.  The  husband  was  obhged  mean- 
while to  sell  his  house,  but  a  clause  was  inserted  in  the  deed 
that  possession  was  not  to  be  given  the  new  owner  till  the 
vendor's  wife  should  -be  delivered.  An  examination  showed 
the  womb  to  be  unimpregnated.  There  had  been  very  scanty 
but  regular  menstruation,  marked  enlargement  of  the  abdomen 
due  to  omental  and  abdominal  fat,  and  many  of  the  subjective 
signs  of  pregnancy.  It  was  a  typical  case  of  pseudocyesis. 
Instances  of  mistakes  in  the  diagnosis  of  pregnancy  could  be 
multiplied  to  a  tedious  length  from  the  author's  own  experience  ; 
but  the  cases  cited  should  be  sufficient  to  demonstrate  the  liability 
to  error.  If  a  physician  w^ould  avoid  such  mistakes,  he  should 
cultivate  the  habit  of  making  a  routine,  methodical,  careful  ex- 
amination of  every  patient  who  may  be  pregnant,^  neglecting  none 
of  the  important  subjective  and  objective  signs,  and  looking  for 
them  in  a  regular  order,  which  will  preclude  negligence  or 
omission. 

The  signs  of  pregnancy,  in  accordance  with  the  laws  of 
symptomatology  in  general,  are  divided  into  the  subjective  and 
the  objective  signs  ;  the  former  being  the  symptoms  experienced 
by  the  patient  herself,  and  the  latter  presenting  themselves  to 
the  senses  of  the  examining  physician. 

The  subjective  signs  of  pregnancy  are  obviously  of  subor- 
dinate value.  The  woman  may  wilfully  deceive  others  or  may 
be  deceived  herself.  She  may  be  unable  to  describe  her  symp- 
toms clearly  or  may  misinterpret  them.  She  may  be  entirely 
unconscious  of  her  condition,  though  pregnant  at  term.  She 
may  not  even  recognize  the  fact  that  she  is  in  labor,  and  the 
birth  of  her  infant  is  her  first  intimation  that  she  was  pregnant.^ 
The  subjective  signs  of  pregnancy,  arranged  as  far  as  possible  in 
the  order  of  their  relative  importance,  are: 

Cessation  of  Menstruation. — This  is  the  most  valuable  of  the 
subjective  signs.  It  is  always  inquired  for  by  the  physician,  and 
is  usually  first  mentioned  by  the  patient  if  she  is  acting  in  good 
faith  ;  but  it  is  by  no  means  a  sure  indication  of  pregnancy,  and  it 
is  not  available  if  a  woman  conceives  during  the  amenorrhea  of 
lactation,  before  menstruation  is  established,  or  after  the  meno- 
pause. Amenorrhea  may  depend  upon  many  other  conditions, 
such  as  change  of  climate,  mental  and  nervous  disorders,  peri- 
uterine inflammations,  the  growth  of  pelvic  and  abdominal 
tumors,  acquired  atresia  of    the  cervix,  anemia,  chlorosis,  and 

1  This  includes  all  females  from  nine  to  sixty-one  years  of  age. 

2  See  "  Unconscious  Pregnancy,"  Gould  and  Pyle,  "Curiosities  of  Medicine," 
p.  72. 


192  PREGNANCY. 

phthisis.  The  fear  of  impregnation  in  the  unmarried,  the  ex- 
pectation of  it  in  newly  married  women,  the  intense  longing  for 
maternity  in  some  sterile  women,  and  a  belief  in  the  existence 
of  pregnancy  in  some  cases  of  pseudocyesis  are  mental  states 
that  have  been  known  to  suspend  the  function.  On  the  con- 
trary, menstruation,  or  a  periodical  bloody  discharge,  persists 
during  the  first  three  months  of  pregnancy  in  a  very  small 
minority  of  cases.  Rarely  the  flow  may  recur  regularly,  though 
scantily,  throughout  the  first  half  or  e\'en  the  whole  of  gesta- 
tion. There  may,  therefore,  be  cessation  of  menstruation  with- 
out pregnancy,  or  persistence  of  menstruation  in  pregnancy. 
The  patient's  statements,  moreover,  are  not  always  to  be  depended 
upon.  She  may  deny  the  cessation  of  menstruation  ;  she  may 
even  stain  her  napkins  regularly  with  the  blood  of  animals  to 
deceive  her  family;^  or,  in  cases  of  spurious  pregnancy,  she  may 
assert  that  the  flow  has  stopped,  when  in  reality  it  persists, 
although  sometimes  so  scantily  as  scarcely  to  attract  her  atten- 
tion. 

Nausea  and  Vomiting. — This  symptom  depends  upon  the  dis- 
tention of  the  gravid  uterus  in  the  beginning  of  pregnancy,  upon  a 
mild  toxemia,  and  upon  the  irritability  of  the  nervous  system. 
It  usually  first  manifests  itself  at  the  sixth  or  seventh  week.  It 
appears  so  constantly  and  to  such  a  marked  degree  in  many  patients 
that  they  regard  it  as  a  certain  indication  of  their  condition,  and 
in  such  cases  considerable  value  may  be  attached  to  the  patient's 
statement  by  the  examining  physician.  '  I  have  had  patients  in 
whom  nausea  and  vomiting  appeared  within  the  week  following  a 
fruitful  coitus,  though  they  did  not  suspect  that  they  were  pregnant.^ 
But  any  irritation  of  the  pelvic  organs  may  produce  the  same  result, 
as  displacement  or  inflammation  of  the  uterus,  congestion  or  in- 
flammation of  the  tubes  and  ovaries,  and  the  growth  of  pelvic 
tumors.  The  stomach  itself  may  be  disordered  and  the  vomiting 
may  not  be  reflex.  On  the  other  hand,  this  symptom  is  entirely 
absent  in  a  considerable  proportion  of  pregnant  women.  Some 
degree  of  salivation  is  usually  associated  with  the  nausea  and 

1  I  was  called  to  empty  the  uterus  of  a  young  girl,  eighteen  years  of  age,  suffer- 
ing- from  an  incomplete  abortion  criminally  induced.  To  this  day  her  family  has  no 
suspicion  of  what  really  occurred.  The  girl  had  put  her  napkins  in  the  wash  at  the 
periods  when  she  should  have  menstruated,  stained  with  beef's  blood  obtained  from 
an  abattoir. 

2  A  Mrs.  E.  under  my  charge  began  vomiting  within  four  days  of  the  fruitful 
coitus  in  four  .successive  pregnancies.  Her  uterus  was  retroflexed  and  adherent. 
A  gentleman  asked  me  to  attend  his  wife  in  confinement,  between  eight  and  nine 
months  later.  When  asked  how  he  could  suspect  pregnancy  so  early,  he_ replied  that 
after  lireakfast  that  morning  he  had  been  seized  with  nausea  and  vomiting,— an  in- 
fallible sign  01)  several  previous  occasions  that  his  wife  had  become  pregnant. 


THE   DIAGNOSIS    OF  PREGNANCY.  1 93 

vomiting  of  pregnancy.  In  rare  cases  the  ptyalism  is  the  pre- 
dominant phenomenon. 

Changes  in  the  Size  and  Shape  of  the  Abdomen. — It  has  been 
asserted  that  at  iirst  there  is  a  hypogastric  flattening,  due  to  the 
sinking  of  the  uterus  during  the  first  few  weeks  of  pregnancy 
on  account  of  its  increased  weight,  but  I  have  ne\'er  found  a 
woman  who  noticed  this  change  in  her  shape.^  The  descent  of 
the  womb,  the  congestion  of  the  pelvis,  and  the  pull  upon  the 
uterovesical  ligament,  however,  cause  an  irritability  of  the  blad- 
der, and  of  this  symptom  the  patient  often  complains.  Later, 
the  abdomen  is  steadily  and  progressively  enlarged  until  the  last 
month,  when  the  subsidence  of  the  uterus  diminishes  the  dis- 
tention of  the  abdomen,  and  at  the  same  time  gives  rise  to 
symptoms  of  pressure  on  the  other  pelvic  organs  and  on  the 
blood-vessels  and  nerves  of  the  pelvis  and  lower  extremities. 

There  are  many  other  causes,  however,  for  abdominal  en- 
largement besides  pregnancy,  as  a  deposition  of  fat  in  the  omen- 
tum and  abdominal  walls,  accumulation  of  fluid  within  the 
abdominal  cavity,  and  the  various  abdominal  and  pelvic  tumors. 
On  the  other  hand,  the  enlargement  of  the  abdomen  due  to 
advanced  pregnancy  may  actually  escape  the  observation  of  the 
patient  herself,*  or  may  be  so  well  concealed  by  tight  lacing  as 
to  be  almost  imperceptible. 

Changes   Due  to    Increased  Blood-supply  to  the  Genitalia  and 

Breasts Owing  to  the  congestion  of  the  parts  there  is  a  tingling 

sensation  and  a  feeling  of  fullness  in  the  breasts,  with  the  appear- 
ance in  them  of  colostrum.  A  sense  of  heat  and  congestion  may 
be  experienced  in  the  pelvic  organs,  and  there  is  very  likely  to  be 
some  leukorrhea.  These  symptoms  are  obviously  of  little  value. 
The  striae  on  the  breasts,  due  to  their  sudden  enlargement,  may 
be  the  first  sign  of  pregnancy  to  attract  the  woman's  attention.^ 

The  sudden  swelling  of  old  varices  is  sometimes  a  valuable 
indication  of  pregnancy. 

Quickening. — This  is  the  name  given  to  the  sensation  experi- 
enced by  the  mother  as  the  result  of  fetal  movements,  which,  as 
a  rule,  become  powerful  enough  to  be  appreciated  by  her  midway 
between  the  fourth  and  fifth  month  of  gestation.  They  may  be 
felt  as  early  as  tiie  third  month  or  not   until   the  last  month  of 

*  The  French  have  a  proverb  :    "  En  ventre  plat 

Enfant  il  y'a." 

2  I  have  seen  an  intelligent  married  woman,  tlie  mother  of  several  children,  be- 
tween seven  and  eight  months  pregnant,  unconscious  of  the  abdominal  enlargement 
and  entirely  ignorant  of  her  condition. 

3  This  was  the  case  in  one  of  my  ]iatients,  a  young  woman  of  exceptionally  good 
social  position,  who  was  illegitimately  pregnant  and,  I  believe,  entirely  ignorant  of 
her  condition. 

13 


194  PREGNANCY. 

pregnancy,  and  some  women  do  not  experience  them  at  all  or 
overlook  their  presence.  They  are  not  felt,  of  course,  when  the 
child  is  dead.  The  woman  interested  to  conceal  her  condition 
will  deny  the  occurrence  of  fetal  movements;  and  other  women, 
deceived  by  the  action  of  the  intestines,  may  honestly  believe  that 
they  feel  them. 

Alterations  in  the  Nervous  System. — The  nervous  system  is 
almost  uniformly  disordered  in  pregnancy.  Characteristic  nerv- 
ous disturbances  are  described  by  the  vast  majority  of  pregnant 
women.  These  are  changes  in  disposition,  mental  peculiari- 
ties, and  perversions  of  tastes.  There  is  often  also  a  sense  of 
dizziness,  a  disposition  to  faint,  and  actual  syncope.  For  ex- 
ample, a  woman  usually  amiable  in  disposition  becomes  irritable, 
sullen,  or  morose;  a  phlegmatic,  placid  individual  may  become 
unusually  vivacious,  and  -the  strangest  fancies  for  eating  unusual 
and  disgusting  articles  may  appear.  IMorbid  desires  impelled 
one  woman  to  murder  her  husband  that  she  might  eat  his  flesh, 
and  another  to  revel  in  the  sight  of  a  butcher  slaughtering  ani- 
mals. In  some  women,  however,  these  nervous  symptoms  are 
entirely  wanting  or  so  slight  as  to  escape  observation.  There 
are  also  many  other  causes  besides  pregnancy  for  changes  in  a 
woman's  nervous  organization,  such  as  nervous  strain  and  hys- 
teria. 

Objective  Signs. — The  objective  symptoms  are  obviously  of 
much  more  importance  and  value  than  the  subjective.  They 
present  themselves  to  the  physician's  senses  of  sight,  touch,  and 
hearing. 

Signs  of  Pregnancy  Ascertained  by  Inspection. — TJie  Woman' s 
Face. — Splotches  of  irregular  pigmentation,  called  chloasmata, 
appear  on  the  brow  and  cheeks,  and  there  are  often  dark  rings 
under  the  eyes.  Moreover,  as  a  physician  questions  a  patient 
in  regard  to  her  condition,  he  may  observe  evidences  of  truth  or 
untruth  in  her  countenance  as  she  replies;  though  the  pregnant 
woman  determined  to  conceal  her  condition  is  often  an  actress  of 
consummate  ability. 

Breasts. — The  mammary  glands  are  enlarged  and  obviously 
distended ;  they  stand  out  prominently  from  the  chest,  and 
tortuous  veins  are  seen  plainly  under  the  skin.  As  pregnancy 
advances,  striae  may  be  observed  in  the  skin  of  the  breasts. 
The  nipples  are  more  prominent  than  in  the  non-pregnant 
condition.  Around  the  nipples  there  is  a  deepening  in  the  color  of 
the  pigmentation  areola,  and  a  widening  of  the  pigmented  area  by 
the  development  of  the  so-called  secondary  areola  of  pregnancy 
(Fig.  129).      In  the  pigmented  area  may  be  observed  the  seba- 


THE  DIAGNOSIS    OF  PREGNANCY.  1 95 

ceous  glands  named  after  Montgomery,  although  he  was  not 
the  first  to  direct  attention  to  them  and  misunderstood  their 
significance.  They  are  often  as  large  as  buckshot  in  the  pregnant 
woman,  and  project  quite  conspicuously  from  the  surface  of  the 
skin.  They  are  frequently,  however,  entirely  absent.  If  the 
breast  is  seized  at  its  base  and  compressed  toward  the  nipple 
between  the  outspread  thumb  and  four  fingers  of  one  hand,  a 
drop  or  two  of  turbid  fluid  (colostrum)  may  be  seen  to  collect 
upon  the  surface  of  the  nipple. 

All  these  mammary  symptoms,  however,  may  be  observed 
independently  of  pregnancy,  and  rarely  may  be  absent  altogether 
in  that  condition.  The  mammary  glands  of  some  women  dis- 
play a  marked  physiological  activity  at  each  menstrual  period, 
even  to  profuse  milk-secretion,  and  it  is  by  no  means  rare  to 
observe  all  the  mammary  signs  of  pregnancy  accompanying  the 
growth  of  a  pelvic  or  abdominal  tumor,  especially  one  of  the 
womb  itself.  Moreover,  the  woman  may  be  impregnated  during 
lactation,  or  some  activity  of  the  glands  may  persist  long  after  a 


Fig.  129. — Showing  the  prominence  of  the  breasts,  the  string  upon  them,  and  the 

pigmented  areola. 

previous  labor.     Under  such  circumstances  the  m.ammary  signs 
of  pregnancy  are  valueless. 

The  Abdomen. — As  pregnancy  advances  the  abdomen  becomes 
more  and  more  prominent ;  obviously  containing  a  tumor  pyri- 
form  in  shape,  with  the  narrow  end  downward,  situated  in  the 
median  line,  and  spreading  with  approximate  equality  to  either 
side.  There  are  other  abdominal  tumors,  however,  which  have 
the  same  shape   as   a  pregnant  womb,  and  the  gravid  uterus  is 


196 


PREGNANCY. 


often  anomalous  in  form.  In  twin  pregnancies,  in  breech  pres- 
entations, in  transverse  positions,  in  some  deformities  of  tlie  fetus, 
in  some   varieties   of  contracted    pelvis,  and  in  the  presence  of 


Fig.  130. — -Xormal  pregnancy  at  term. 


Fig.  131. — Uterus  deformed  Ijy  scoliosis  of  the  spine  (paralytic) 


Other  tumors  coincident  with  pregnancy,  the  pregnant  uterus  is 
altered  in  shape.  Displacements  of  the  uterus  may  also  give  it 
an  unusual  appearance  in  pregnancy. 


THE  DIAGXOSIS    OF  PREGNANCY. 


197 


Fig.  132. — Six  months  pregnant, 
with  a  large  fibroid  tumor.  Seen  in 
consultation  with  Dr.  R.  II.  Hamill. 


Fig.   133. — Breech  presentation,  at 
term. 


Fig.     134 — The   pendulous   belly   of 
rachitis.      Pregnant  at  term. 


Fig-    135- —Twins. 


198 


PREGNANCY. 


Fig.  136. — Pregnant  uterus  distorted  by  rachitic  kyphoscoliosis. 


Fig.  137. — Linea  nigra,  well  marked  above  and  below  the  umbilicus.  Exaggera- 
tion of  the  pigmentation  around  the  nipples.  Half-breed  Indian  squaw.  (University 
Maternity.) 


THE   DIAGNOSIS    OF  PREGNANCY. 


199 


The  umbilicus  at  the  sixth  month  is  level  with  the  surface  of 
the  abdomen,  and,  later,  pouts.  It  is  surrounded  by  a  ring  of  pig- 
mentation, which  extends  above  as  high  as  the  fundus  uteri,  and 
below  along  the  linea  alba,  which  in  pregnancy  becomes  the  linea 
nigra  (Figs.  137,  138).  By  a  disorder  in  the  arrangement  of  the 
fibers  in  the  cutis  there  appear  to  be  cracks  in  the  skin  of  the  ab- 
domen, especially  toward  the  flanks,  over  the  surface  of  the  iliac 
bones,  ancl  upon  the  outer  aspects  of  the  thighs.  There  is  a  dis- 
position to  hypertrichosis  all  over  the  body,  but  most  marked  on 
the  abdomen,  especially  along  the  linea  alba  (Halban).  If  the 
pregnancy  is  far  advanced,  and  if  the  fetus  is  alive,  fetal  move- 
ments may  be  plainly  seen.  These  are  of  two  kinds  :  there  is  g, 
heaving  movement  of  the  fetal  back,  and  a  sharp,  sudden  tap  of 
the  fetal  extremities.  Fetal  movements,  if  unmistakable,  are 
positive  signs  of  pregnancy,  but  they  have  been  simulated  by 
twitching  of  the  abdominal  muscles  and  by  the  vermiform 
movements  of  the  intestines. 

Vagina  and  Vulva. — The  mucous  membrane  of  the  vestibule 
and  of  the  vagina  assumes  a  purple  hue  in  the  later  months  of 
gestation,  which  has  been  aptly  com- 
pared in  color  to  the  lees  of  wine.  The 
discoloration  of  the  mucous  membrane 
of  the  vagina  and  of  the  vaginal  intro- 
itus  is  usually  most  marked  upon  the 
inner  surface  of  the  labia  majora  and 
upon  the  fold  of  vaginal  mucous  mem- 
brane on  the  anterior  wall  that  comes 
into  view  when  the  labia  are  separated 
(Plate  8,  Figs.  3  and  4).  It  is  occa- 
sionally confined  to  the  fossa  navicula- 
ris  (Plate  8,  Fig.  2),  or  to  the  deeper 
portions  of  the  vaginal  rugae.  The 
pigmentation  of  the  mucous  membrane 
begins  in  some  cases  as  early  as  the 
fourth  week.  Chadwick  ^  in  2^1  cases 
found  it  diagnostic  in  thirteen  per  cent,  at  the  end  of  the  second 
month;  in  forty-six  per  cent,  at  the  end  of  the  third  month.  John- 
son ^  calls  attention  to  a  regularly  recurring  change  of  color  in  the 
cervix  from  violet  to  pink  as  an  early  and  reliable  sign  of  })rcgnancy. 
It  is  due  to  the  intermittent  contractions  of  the  uterus.  The 
violet  color  of  the  vaginal  and  vulvar  mucous  membrane  is  by  no 

^  "Tr.  Am.  Gyn.  Soc,"  vol.  ii,  1886,  p.  399.     See  also  Farlow,  "The  Boston 
Med.  and  Surg.  Jour.,"  vol.  cxvli,  No.  3,  1887. 
^  "  Journ.  Am.  Med.  Assoc,"  Feb.  20,  1904. 


Fig.    13S. — Linea  nigra,  visible 
only  below  the  umbilicus. 


200 


PREGNANCY. 


means  an  infallible  sign  of  pregnancy.  It  is  often  absent  alto- 
gether in  early  pregnancy,  and  I  have  frequently  noted  its  entire 
absence  at  term.  There  are,  moreover,  other  conditions  than 
pregnancy  which  can  give  rise  to  it :  erethism,  pelvic  tumors, 
intense  congestion  of  the  pelvis.  But  even  if  the  blue  discolora- 
tion is  not  visible,  one  may  always  notice  in  the  later  months  a 
transformation  of  the  pink  color  of  the  mucous  membrane  of  the 
introitus  into  a  bright  scarlet. 


Fig.     139. — Hegar's   sign   of  pregnancy   elicited    by   a   combined   vaginal    and 
abdominal  examination. 


Signs  Appreciated  by  the  Sense  of  Touch. — Abdominal  Palpa- 
tion.— By  this  method  are  learned  the  size  and  shape  of  the 
uterus,  and  after  the  sixth  month  the  teta^  back,  head,  and  ex- 
tremities may  be  felt.  ^  By  placing  the  ouistretched  hand  over 
the  fundus,  the  intermittent  uterine  contractions,  to  which  atten- 
tion was  first  called  by  Braxton-Hicks,  are  perceived.  At  inter- 
vals of  about  ten  minutes  throughout  gestation  the  whole  uterine 
muscle  contracts  as  it  does  in  a  labor-pain,  the  uterus  hardening 


1  For  a  more  extended  description  of  abdominal  palpation  see  "  Mechanism  of 
Labor." 


Plate  7. 


/ 


,4' 


Figure  i.  —  15rea.sl  of  a  non-pregnaiU  woman  of  ilie  Monde  iv|K'. 

Kij^ures  2  and  .4. —  Breasts  of  pregnant  women  of  llic  liniiu-l  type. 

Figure  3. — Hreast  of  a  pregnant  woman,  a  blonde. 

Paiiilcd  from  life,  showing  the  irreguhir  distril)iition  of  Montgomery's  glands 
and  comparative  distention  of  the  veins  in  llie  ])regnant  and  the  non  pregnant  woman 
when  the  breasts  arc  allowed  to  hang  UM-.uppc)rled  by  ihe  clDthing  fui- a  few  minutes. 


Plate  8. 


&. 


3. 


4. 


r 


o.<T 


Figure  i. — Normal  color  of  the  vaginal  mucous  membrane  in  a  woman  not 
pregnant  (blonde). 

Figure  2. — Color  of  vaginal  mucous  membrane  and  introitus  in  a  brunet. 

Figure  3. — Color  of  vaginal  mucous  membrane  and  introitus  in  a  negress. 

Figure  4. — Color  of  the  vaginal  mucous  membrane  in  a  light  blonde. 

Note  the  scarlet  color  of  the  mucous  membrane  of  the  introitus,  in  addition  to  the 
blue  discoloration.  The  former  is  always  ])resent,  even  if  the  latter  is  absent.  The 
complexion  of  the  individual  does  not  necessarily  influence  the  depth  of  the  blue 
discoloration.     In  figure  2,  a  dark  brunet,  it  is  lighter  than  in  figure  4,  a  light  blonde. 


THE  DIAGNOSIS    OF  PREGNANCY.  201 

under  the  hand  so  that  its  contents  can  no  longer  be  easily  ap- 
preciated. This  sign  is  available  at  the  end  of  the  third  month, 
and  although  it  may  be  produced  by  any  tumor  distending  the 
uterine  walls,  as  a  collection  of  blood,  an  intra-uterine  polyp,  or  a 
soft  myoma,  it  is  almost  a  positive  sign.  It  may,  however,  occur 
sympathetically  in  extra-uterine  pregnancy,  and  it  is  said  that  the 
contractions  of  an  overdistended  bladder  may  be  mistaken  for 
the  rhythmical  contractions  of  the  gravid  womb.  Finally,  fetal 
movements  may  be  felt  as  pregnancy  advances.  The  sensation 
conveyed  to  the  hand  is  usually  that  of  a  finger-tap  under  a 
blanket.  The  other  fetal  movement,  however, — a  heaving  action 
of  the  back, — is  equally  characteristic.  This  symptom  is  natur- 
ally a  positive  sign  of  gestation.  Fetal  movements  may  be  ex- 
cited by  placing  a  cold  hand  suddenly  upon  the  woman's  abdo- 
men, or  by  pushing  the  fetus  about  in  the  womb. 

Combined  Examination. — The  cervix  in  pregnancy  is  notably 
softened  as  a  result  of  the  increased  blood-supply  and  an  edema 
of  the  part.  Goodell  is  the  author  of  the  ready  rule  of  practice, 
that  when  the  cervix  is  as  hard  as  one's  nose  pregnancy  does 
not  exist,  but  when  it  is  as  soft  as  one's  lips  pregnancy  is  likely. 

Rapidly  growing  myomata,  however,  acute  metritis,  and 
hematometra  can  produce  as  soft  a  cervix  as  is  felt  in  pregnancy, 
and  should  the  neck  of  the  pregnant  womb  be  the  seat  of  an  old 
injury,  with  dense  and  extensive  cicatrices,  or  should  the  cervix 
be  cancerous  or  syphilitic,  there  may  be  no  appreciable  soften- 
ing in  pregnancy. 

Johnson^  declares  that  a  change  in  consistency  of  the  cervix 
may  be  noted  at  regular  intervals  very  early  in  gestation,  being 
the  first  appearance  of  the  intermittent  contractions  that  are  felt 
later  by  abdominal  palpation.  To  detect  this  sign  the  finger  must 
be  kept  in  the  vagina  for  ten  minutes  at  a  time  perhaps,  which  is, 
to  say  the  least,  inconvenient. 

Hegar's  sign  of  early  pregnancy  depends  upon  a  marked 
softening  of  the  lower  uterine  segment,  by  which  it  appears  on 
combined  examination  that  the  body  and  the  cervix  are  discon- 
nected, though  on  closer  examination,  the  outer  edges  of  the 
lower  uterine  segment  appearing  a  little  firmer  than  the  inter- 
mediate portions,  it  seems  that  the  cervix  is  joined  to  the  body 
of  the  womb  by  two  indistinctly  appreciable  longitudinal  bands. 
The  best  method  to  elicit  this  symptom  is  to  insert  the  forefinger 
far  into  the  rectum  and  the  thumb  into  the  vagina,  while  the 
womb  is  pressed  down  by  the  other  hand  applied  upon  the 
abdominal  wall. 

^  Loc.  cit. 


202 


PREGNANCY. 


It  is  not  always  necessary,  however,  to  make  a  rectal  exami- 
nation. By  combined  pressure,  either  through  the  anterior  or 
posterior  vaginal  walls  and  the  abdominal  wall  above,  the  finger- 
tips can  be  brought  into  relationship  with  the  lower  uterine 
segment.  Hegar's  sign  is  by  no  means  a  certain  one.  It  is  not 
invariably  appreciable  in  pregnancy,  and  it  might  be  felt  in  a  non- 
pregnant uterus,  softened  by  congestion,  inflammation,  or  the 
presence  in  it  of  fluid. 

The  uterus  may  be  asymmetrically  enlarged,  one  side  being 
greater  than  the  other,  and  a  longitudinal  line  or  furrow  separat- 
ing the  two  (Braun-Fernwald's  sign). 

Enlargement  of  the  uterus,  with  a  change  in  its  shape  and 
consistency,  is  one  of  the  most  important  symptoms  in  the  early 
weeks.  The  womb  becomes  more  spherical  in  outline,  softer  in 
consistency,  and  distinctly  enlarged,  while  there  is  usually  a 
marked  anteflexion  in  consequence  of  the  weight  of  the  body  of 
the  uterus  and  of  the  softened  lower  uterine  segment.  By  plac- 
ing one  hand  over  the  fundus  and  the  fingers  of  the  other  in  the 
vagina  an  impulse  may  be  conveyed  by  the  latter  to  the  uterine 
contents,  which  are  displaced  upward,  communicating  an  impact 


Fig.  140. — The  shape  and  size  of  the 
non-pregnant  uterus. 


Fig.  141. — The  shape  and  size  of  tlie  uterus 
altered  by  early  pregnancy  (Budin). 


to  the  external  hand  and  falling  again  into  its  original  situation  ; 
a  tap  is  felt  upon   the   uterine  and  vaginal  walls   by  the  fingers 


THE   DIAGNOSIS    OF  PREGNANCY.  203 

applied  internally.  To  this  symptom  the  name  "  ballottement " 
has  been  given,  and  to  the  experienced  examiner  it  is  a  positive 
sign  of  the  condition,  though  a  small  cystic  tumor  of  the  ovaiy 
with  a  long  pedicle  may  simulate  it  closely,  and  the  same  symp- 
tom might,  of  course,  be  elicited  in  an  advanced  extra-uterine 
gestation. 

Symptoms  Ascertained  by  Auscultation.  —  Mayor,  a  surgeon 
of  Geneva,  was  the  first  to  discover,  in  18 18,  that  the  fetal  heart- 
sounds  could  be  heard  by  applying  the  ear  to  the  abdomen  of  a 
pregnant  woman  when  the  child  is  alive.  Three  years  later  this 
valuable  symptom  of  pregnancy  was  described  in  an  article  by 
Kergaradec  presented  to  the  French  Academy.  It  is  a  symptom 
available  as  early  as  the  fifth  month,  although  its  value  increases 
with  the  advance  of  pregnancy.  The  fetal  heart  beats  at  the 
rate  of  about  120  to  160  a  minute,  and  the  sound  has  aptly  been 
compared  to  the  ticking  of  a  watch  under  a  pillow.  The  beat  is 
a  double  one,  as  in  the  adult  heart.  The  area  of  the  maximum 
intensity  of  the  fetal  heart-sounds  in  anterior  positions  of  the 
vertex  is  about  an  inch  below  the  umbilicus  to  the  left  or  the 
right  of  the  median  line,  or  in  posterior  positions  of  the  vertex 
in  the  flanks  on  a  line  passing  through  or  somewhat  below  the 
umbilicus.  In  breech  presentations  the  maximum  intensity  is 
usually  above  the  umbilicus,  and  in  transverse  positions  the 
pulsations  may  be  heard  low  upon  the  abdominal  wall  near  the 
symphysis.  Occasionally  they  can  best  be  heard  over  the  fundus 
uteri,  the  sound  being  transmitted  by  the  fetal  spine.  Their 
absence  by  no  means  excludes  the  existence  of  pregnancy.  They 
are  not  heard  if  the  child  is  dead,  if  there  is  an  abnormal 
quantity  of  liquor  amnii  in  the  uterus,  if  the  abdominal  walls 
are  excessively  thick,  or  in  certain  positions  of  the  fetus.  On 
the  other  hand,  the  beat  of  the  maternal  aorta  has  often  been 
mistaken  for  the  fetal  heart,  though  this  error  is  easily  avoidable 
if  one  feels  the  maternal  pulse  as  he  listens  for  the  fetal  heart- 
sounds,  and  remembers  that  the  aortic  impulse  is  a  single,  the 
fetal  heart-beat  a  double,  sound. 

Another  sign  of  pregnancy  appealing  to  one's  sense  of 
hearing  is  dullness  on  percussion  along  the  median  line  of  the 
abdomen  and  for  some  distance  on  either  side.  It  is  possible, 
however,  in  very  rare  cases  of  excessive  tympanitic  distention  of 
the  intestines,  to  obtain  a  tympanitic  note  all  over  the  anterior 
wall  of  the  abdomen,  though  the  woman  may  be  pregnant  at 
term.  In  such  cases  the  distended  intestines  have  surrounded 
the  womb  and  cover  its  anterior  surface. 

The  uterine  bruit,  svnchronous  with  the  maternal  heart-beat, 


204  PRE  GNA  NC  V. 

is  often  heard  in  pregnancy,  but  it  may  be  heard  also  in  large 
uterine  myomata  and  in  ovarian  cysts.  It  can  usually  best  be 
distinguished  on  the  left  lateral  aspect  of  the  pregnant  womb, 
as  it  is  caused  by  some  obstruction  to  the  blood  flowing  through 
the  uterine  artery.  The  funic  souffle,  present  in  about  fifteen  per 
cent,  of  cases,  if  heard,  is  diagnostic  of  pregnancy.  It  is  a  high- 
pitched,  whistling,  or  hissing  murmur,  synchronous  with  the 
fetal  heart-beat.  It  is  caused  by  some  obstruction  to  the  flow 
of  blood  through  the  umbilical  arteries. 

The  fetal  movements  may  be  heard,  in  auscultation  of  the 
abdomen,!  as  a  dull  thud  against  the  abdominal  walls.  Feeble 
movements  may  be  heard  as  early  as  the  fourth  month.  It  was 
while  listening  for  the  fetal  movements  that  Mayor  first  heard 
the  fetal  heart-sounds. 

In  auscultating  the  abdomen  of  a  woman  for  the  signs  of 
pregnancy,  the  examining  physician  should  first  use  his  ear 
directly  applied  to  the  abdomen  with  nothing  but  a  thin  towel 
intervening.  A  stethoscope  should  also  be  employed,  however, 
in  doubtful  cases  and  in  situations  where  the  ear  can  not  be  con- 
veniently applied. 

A  positive  diagnosis  of  pregnancy  before  the  sixth  week  is 
impossible,  and  the  diagnosis  may  be  only  presumptive  until 
the  fetal  heart-sounds  can  be  heard  and  fetal  movements  are 
felt. 

Clinically,  the  signs  of  pregnancy  may  be  divided  into  those 
of  three  trimesters,  or  periods  of  three  months  each.  It  is  useless 
for  the  practitioner  to  look  for  certain  signs  in  one  trimester  only 
available  in  the  next.  Fi7^st  trimester. — In  this  period  the  follow- 
ing signs  of  pregnancy  are  available  :  Enlargement,  change  in 
shape  and  bogginess  of  the  uterine  body,  soft  cervix,  enlargement 
and  functional  activity  of  the  breasts,  Hegar's  sign,  cessation 
of  menstruation,  nausea,  and  vomiting.  The  second  trimester 
exhibits,  in  addition  to  the  above,  enlargement  of  the  abdomen, 
intermittent  contractions  of  the  uterus,  feeble  fetal  movements, 
ballottement,  fetal  heart-sounds,  and  blue  discoloration  of  the 
vaginal  mucous  membrane.  In  the  tJiird  trimester  all  the  s}-mp- 
toms  just  enumerated  become  more  easily  appreciable.  The 
outlines  of  the  fetal  body  are  distinguishable  by  abdominal 
palpation,  and  the  presenting  part  may  be  felt  through  the  roof 
of  the  vaginal  vault. 

Differential  Diagnosis  of  Pregnancy  from  Other  Pelvic  and 
Abdominal    Tumors. — Early  pregnancy  must   be   distinguished 

^  First  reported  by  Kergaradec  in  1822. 


THE   DIAGNOSIS   OF  PREGNANCY.  '  205 

occasionally  from  small  fibromyomata,  hematometra,  hydrometra, 
and  pyometra,  small  cystic  and  solid  tumors  of  the  broad  ligaments 
and  appendages,  inflammatory  swellings  of  the  broad  ligaments 
and  ovaries  including  exudates.  In  all  tumors  not  involv^ing  the 
uterus  itself  the  latter  may  be  mapped  out  by  careful  bimanual 
examination,  which  also  determines  its  size,  consistency,  and 
shape,  and  thus  decides  whether  it  is  pregnant  or  not.  In  the 
case  of  pelvic  and  peritoneal  exudate  it  may  be  impossible  to 
feel  anything  through  the  vaginal  vault  except  the  inflammatory 
mass  from  which  the  cervix  projects  like  a  nipple.  It  may 
therefore  be  impossible  to  tell  whether  there  is  a  coincident  preg- 
nancy and  pelvic  inflammation  except  by  an  exploratory  abdomi- 
nal section,  which  would  not,  however,  be  justified  simply  to 
clear  up  the  diagnosis.  Time  would  decide  the  question.  If 
the  tumor  is  situated  in  the  uterus  itself,  the  differential  diagnosis 
may  not  be  easy,  but  is  almost  always  possible.  Fibromyomata 
are  usually  stony  hard,  irregular  in  shape,  and  cause,  as  a  rule, 
menorrhagia.  Accumulations  of  fluid  in  the  uterus  may  for  a 
time  be  very  puzzling,  but  there  is  usually  the  history  of  cramp- 
like pains  at  the  menstrual  periods,  the  amenorrhea  has  often 
been  of  longer  duration  than  would  be  the  case  in  early  preg- 
nancy, there  may  have  been  an  impossibility  of  impregnation,  and 
the  congenital  or  acquired  atresia  of  the  cervix  is  almost  always 
demonstrable. 

The  differentiation  between  later  pregnancy  and  the  other  ab- 
dominal tumors  is  made  by  the  patient's  history,  by  inspection, 
abdominal  palpation,  auscultation,  and  a  combined  examination. 
It  should  be  remembered  that  the  pregnant  uterus  is  b}^  far  the 
commonest  abdominal  tumor.  It  is  numbered  by  the  thousands 
in  all  large  communities,  while  other  growths  are  rare.  All 
women,  therefore,  between  the  ages  of  nine  and  sixty-one,  with 
an  abdominal  tumor,  should  be  regarded  as  pregnant  until  the\' 
are  proved  to  be  otherwise,  though  the  physician  will  do  well  to 
keep  his  suspicion  to  himself  and  to  keep  an  open  mind,  so  that 
he  may  not  suffer  in  reputation  from  an  egregious  mistake  or  be 
responsible  for  a  tragedy  like  that  of  Lady  Flora  Hastings, 

Many  abdominal  tumors  may  be  distinguished  from  preg- 
nancy at  a  glance;  thus,  obesity  (Fig.  142);  an  abdominal  hernia 
(Fig.  143);  a  tumor  in  the  upper  abdomen  (Fig.  144);  an  enor- 
mous abdominal  distention  from  a  large  ovarian  cyst,  ascites,  or 
a  huge  myoma  (Figs.  145-147)  look  so  unlike  the  abdominal 
distention  of  pregnancy  that  no  suspicion  of  gestation  enters  tlic 
obscrvers's  mind,  but  it  should  be  remembered  thai  there  ma}' 
be  a  coincident  pregnancy  with  any  of  the  abdominal  tumors  and 


206 


PREGNANCY. 


that  the  pregnant  uterus  may  assume  a  distorted  form,  occupy 
an  unusual  position,  and  reach  an  enormous  size  in  consequence 
of  multiple  pregnancy,  fetal  monstrosity,  deformities  of  the  spine, 
tight  lacing,  or  hydramnios.^ 

There  are  m.any  abdominal  tumors  (Figs.   148,  149)  that  re- 
semble closely  or  exactly  the  pregnant  uterus  on  inspection;  thus, 


fig.  142. — Obesity. 


a  fibromyoma,  an  ovarian  cyst,  tympanites,  or  a  distended  blad- 
der may  furnish  a  degree  and  kind  of  abdominal  distention  quite 
like  that  of  pregnancy,  and  in  the  two  former  instances  there  may 
have  been  an  amenorrhea  corresponding  in  duration  with  that  of 
pregnancy.  In  t\YO  cases  under  the  author's  notice,  one  of  a 
fibroid  tumor,  the  other  of  an  ovarian  cyst,  the  patients'  state- 
ment   to  the  examining  physicians   that   they  had  missed  their 

1  Figures   142  to  149  are  from  the  author's  gynecologic  service  in  the  Howard 
Hospital,  Philadelphia. 


THE   DIAGNOSIS   OF  PREGNANCY. 


207 


Fig.   143. — Hernia. 


Fii:.    144. — Sarcoma  of  tlie  liver. 


208 


PREGNANCY. 


Fig.   145- — Ovarian  cyst. 


Fig.  146. — Carcinoma  of  uterus  and  ascites. 


THE  DIAGNOSIS   OF  PREGNANCY. 


209 


Fig,    147. — Tuberculous  peritonitis  and  ascites. 


Fig.   148. — Distended  bladder. 


14 


2IO 


PREGNANCY. 


sickness  for  nine  months  gave  rise  to  such  a  strong  preconceived 
idea  of  pregnancy  that  a  false  diagnosis  was  made.  The  correct 
diagnosis  can  almost  certainly  be  made  by  a  systematic  search 
for  all  the  subjective  and  objective  signs  of  pregnancy  in  regular 
order,  and  in  their  absence  by  discovering  the  characteristic 
symptoms  of  the  abdominal  growth  that  may  be  present.  In 
the  case  of  tympanitic  distention  of  the  abdomen,  deep  abdominal 
palpation — if  necessary,  under  anesthesia — and  percussion  show 
the  absence  of  a  solid  abdominal  tumor. 


Fig.  149 — Fibroid  tumor. 

Estimation  of  the  Duration  of  Pregnancy. — If  the  date  of 

the  fruitful  coitus  can  be  ascertained,  labor  may  be  expected,  on 
the  average,  two-hundred  and  seventy-one  days  later.^  Ordi- 
narily, the  history  of  cessation  of  menstruation  is  depended  upon 
in  making  an  estimate  of  the  probable  date  of  labor.  Nagele  ^ 
is  the  author  of  the  convenient  rule  for  predicting  the  date  of  the 
expected  confinement  by  counting  back  three  months  from  the 
first  day  of  the  last  menstruation  and  adding  seven  days.  For 
seven  months  of  the  year  this  method  is  absolutely  correct.  In 
April  and  September  six  days,  in  December  and  January  five 
days,  and  in  Februar}'  four  days  should  be  added  to  obtain  the 
date  of  a  period  two  hundred  and  eighty  days  after  the  first  day 
of  the  last  menstruation.  It  is  to  be  noted  that  the  predic- 
tion  of    the    date   of   labor   can    never    be   more   than   approxi- 


1  Ahlfeld,  "  Monat.  f.  Geburtsh.,"  Bd.  xxxiv,  p.  20S,  based  on  425  cases. 

2  "  Lehrbuch  der  Geburtsbiilfe." 


THE   DIAGNOSIS    OF  PREGNANCY.  211 

mately  accurate,  as  labor  occurs  only  exceptionally  two  hun- 
dred and  eighty  days  from  the  first  day  of  the  last  menstrual 
period.  1  A  variation  of  a  few  days  either  way  is  the  rule,  and 
prolongation  of  pregnancy,  even  to  a  month  or  more,  is  by 
no  means  exceedingly  rare.  Lowenhardt  has  proposed  multi- 
plying by  ten  the  number  of  days  between  the  last  normal 
menstruation  and  the  one  preceding,  thus  predicting,  with  a 
greater  accuracy  than  is  otherwise  possible,  the  probable  dura- 
tion of  pregnancy.  Thus,  if  the  interval  is  twenty-six  instead 
of  twenty-eight  days,  the  pregnancy  will  last  two  hundred  and 
sixty  days.  Lusk  says  he  has  seen  occasionally  a  curious  con- 
firmation of  Lowenhardt's  view,  but  my  own  experience  would 
not  lead  me  to  prefer  this  method  to  Nagele's.  If  the  patient  is 
not  menstruating  when  she  conceives,  as  in  lactation,  if  the  his- 
tory of  menstruation  is  not  attainable,  or  is  not  to  be  depended 
upon,  an  approximate  idea  of  the  date  of  pregnancy  may  be 
gained  by  noting  the  height  of  the  fundus.  At  the  fourth 
month  it  rises  above  the  pelvic  brim  ;  at  the  fifth  it  is  midway 
between  the  umbilicus  and  the  symphysis  ;  at  the  sixth  month 
on  a  level  with  the  umbilicus  ;  at  the  seventh  month  about  four 
fingers'  breadth  above  the  navel  ;  at  the  eighth  month  about 
midway  between  the  umbilicus  and  the  xiphoid  cartilage  ;  at  the 
ninth  month  the  fundus  reaches  its  highest  level  near  the  xiphoid 
cartilage  ;  during  the  ninth  month  the  fundus  descends  again 
almost  to  the  level  at  which  it  was  at  the  eighth  month,  the  pre- 
senting part  having  entered  the  superior  strait.  The  date  of 
quickening  is  of  some  value  in  estimating  the  duration  of  preg- 
nancy. It  may  be  expected  in  the  twentieth  week  in  primigrav- 
idae,  in  the  twenty-first  and  twenty-second  weeks  in  multigravidae. 
But  this  symptom  is  exceptionally  observed  as  early  as  the 
fifteenth,  thirteenth,  or  even  the  tenth  week,  and  some  women  do 
not  notice  it  till  the  seventh  month. 

Diagnosis  of  the  Life  or  Death  of  the  Fetus. — The  fetal 
heart-sounds  are  a  most  valuable  sign  of  fetal  life  when  they  can 
be  heard.  Positive  knowledge  on  the  part  of  the  patient  of  fetal 
movements  is  also  of  great  value,  and  if  the  movements  can  be 
felt,  seen,  or  heard  by  the  physician,  there  is,  of  course,  positive 
evidence  of  fetal  life.  All  the  signs  of  pregnancy  without  fetal 
heart-sounds  or  fetal  movements  usually  mean  a  dead  fetus. 
The  most  valuable  sign  of  fetal  death  in  pregnancy  is  the  cessation 
of   growth  in  the  alxlomen,  which  is  determined    by  successive 

1  Ahlfeld's  statistics,  based  on  653  labors,  show  that  pret;nancy  was  ended  in 
the  thirty-eighth  week  in  15.93  per  cent.,  in  the  thirty-ninth  in  27.56  percent.,  in 
the  fortieth  in  26.19  per  cent.,  and  in  the  forty-first  in  10  per  cent,  of  the  cases. 


212 


PREGXAxYCY. 


THE  DIAGNOSIS   OF  PREGNANCY.  213 

weekly  measurements  of  the  abdomen  with  a  tape-measure,  care 
being  exercised  to  ascertain  on  each  occasion  the  maximum  girth. 
If  the  fetus  is  ahve,  there  is  a  steady  increase  from  w^ek  to  week. 
If  it  is  dead,  there  is  no  increase  in  the  abdominal  measurements, 
and  there  ma}'  be  a  decrease.  For  a  more  extended  account  of 
the  diagnosis  of  fetal  life  and  death  the  student  is  referred  to  the 
section  on  the  diseases  and  death  of  the  fetus. 

It  is  obvious  that  a  diagnosis  of  life  or  death  of  the  fetus  i.s 
often  of  great  importance,  as  a  physician  would  be  inclined  to 
induce  labor  to  evacuate  the  womb  of  a  dead  fetal  body  if  he 
could  be  certain  that  the  child  had  died  ;  and  a  knowledge  of 
fetal  life  or  death  would  influence  the  treatment  of  nephritis  or 
of  other  complicating  diseases  of  gestation.  In  case  of  doubt  it 
should  be  assumed  that  the  fetus  is  still  alive. 

Diagnosis  of  the  Sex  of  the  Fetus. — It  was  thought  for 
some  time  that  the  diagnosis  of  fetal  sex  could  be  made  by 
listening  to  the  rate  of  the  fetal  heart -beat, — a  rate  of  120  to 
140  in  the  minute  indicating  the  probability  of  a  male  fetus,  while 
a  quicker  heart-beat  is  indicative  of  a  female  child  ;  but  observa- 
tions conducted  by  Budin,  also  those  in  the  Boston  Lying-in 
Hospital,  and  others  made  by  the  author,  show  that  there  is  such 
a  variability  in  the  fetal  heart-rate  from  time  to  time  that  it  is 
impossible  to  predict  by  this  means  the  sex  of  the  fetus. 

Diagnosis  of  a  Prior  Pregnancy. — The  determination  of 
this  point  may  be  of  medicolegal  importance.  A  vaginal  ex- 
amination detects  some  degree  of  laceration  of  the  cervix, 
usually  bilateral.  The  cervix  is  large  and  cylindrical.  The 
cervical  canal  is  patulous,  usually  admitting  the  first  joint  of  the 
index  finger.  There  are  old  scars  upon  the  skin  of  the  ab- 
domen, pointing  to  a  former  distention  of  the  abdominal  cavity, 
the  recti  muscles  are  separated  by  at  least  three  finger-breadths, 
and  the  abdominal  walls  are  more  flaccid  than  in  a  primigravida 
or  a  nuUiparous  woman.  The  pelvic  floor  may  be  relaxed,  and 
there  may  possibly  be  tears  of  the  levator  ani  muscles.  The 
hymen  is  not  only  torn,  but  is  in  great  part  destroyed,  the  rem- 
nants forming  the  caruncula^  myrtiformes.  The  vaginal  mucous 
membrane  is  smooth,  and  the  vulva  gapes  so  that  b}^  separation 
of  the  labia  majora  often  a  great  part  of  th-e  vaginal  canal  can 
be  brought  into  view.  There  is  often  some  degree  of  cystocele, 
the  anterior  vaginal  wall  bulging  downward  and  forward  into  the 
vulvar  orifice. 

The  breasts  are  ill  supported  and  sag  down,  while  upon  the 
skin,  especially  at  the  base  of  the  glands,  may  be  seen  the  white 
and  crlistenincr  scars  of  old  striae. 


214 


PREGNANCY. 


Parturition  in  very  rare  cases,  especially  if  the  child  is  pre- 
mature and  small,  may  leave  hardly  a  trace  behind  it,  and  the 
delivery  of  a  submucous  fibroid  may  produce  the  same  lacera- 
tions of  the  cervix  and  pelvic  floor  that  occur  in  childbirth. 

Pseudocyesis,  or  Spurious  Pregnancy — In  women  who 
ardently  desire  offspring,  in  those  who  fear  impregnation,  and  in 
individuals  who,  without  longing  for  or  dread  of  maternity,  believe 

themselves  pregnant,  the 
subjective  and  some  of  the 
objective  signs  of  preg- 
nancy may  appear  to  so 
striking  a  degree  that  the 
patient  herself  is  com- 
pletely deceived,  and  not 
infrequently  her  physician 
shares  her  belief  in  the 
existence  of  pregnancy.  I 
was  once  consulted  by  a 
prostitute  who  firmly  be- 
lieved she  had  been  preg- 
nant for  a  year,  or  ever 
since  her  occupation  had 
exposed  her  to  the  dan- 
ger of  impregnation.  The 
abdomen  was  distended ; 
the  breasts  were  enlarged 
and  painful,  though  not  se- 
creting.; menstruation  was 
very  scanty  and  irregular, 
and  the  woman  asserted 
that  she  felt  fetal  ^^^^e- 
ments.    The  abdomu.. .  dis- 

Fig.  151.  — Pseudocyesis  :  Amenorrhea  tention  waS  due  tO  fat  and 
for  eight  months,  but  vicarious  menstruation  eras.  The  uteruS  waS  un- 
from  nose  every  month.     The  uterus  is  nor-       .  .1.    j         t    i  r 

mal  in  size,  position  and  mobility.  The  ab-  impregnated.  I  have  fre- 
dominal  distention  is  due  solely  to  tympanites  qUently  Seen  women  wllO 
^"*^  f^'-  put  on  an  excessive  amount 

of  abdominal  and  omental 
fat  as  they  approach  middle  age,  and  who,  in  consequence  of 
the  abdominal  enlargement,  believe  themselves  pregnant.  Men- 
struation may  be  entirely  absent  or  so  scanty  as  scarcely  to  attract 
the  woman's  attention,  and  all  the  subjective  signs  of  pregnancy 
may  be  accurately  described.  It  often  requires  in  these  cases  an 
examination  under  anesthesia  before  the  unimpregnated  condition 
of  the  uterus  can  be  detected.      Weir  Mitchell  asserts  that  once 


DISEASES   OF  THE    GENITALIA.  215 

these  women's  minds  are  disabused  of  the  idea  that  they  are  preg- 
nant, the  abdominal  enlargement  rapidly  subsides,  and  all  the 
subjective  symptoms  of  pregnancy  immediately  disappear.  Oc- 
casionally it  is  imposible  to  convince  a  woman  that  she  is  not 
pregnant  if  she  has  allowed  the  idea  of  pregnancy  to  take  entire 
possession  of  her  mind.  A  little,  wizened  old  lady  with  gray  hair, 
apparently  sixty  years  old,  applied  for  admission  at  the  Maternity 
Hospital  of  Philadelphia.  She  volunteered  the  statement  that 
many  years  before  she  had  subjected  herself  to  the  dangers  of  ille- 
gitimate impregnation,  and  that  ever  since  she  had  been  pregnant. 
Nothing  could  convince  her  of  the  truth,  and  she  indignantly 
left  the  hospital  firmly  possessed  of  her  monomaniacal  idea.  The 
case  shown  in  figure  151  is  interesting.  The  woman  had  had 
an  attack  of  pelvic  peritonitis  just  nine  months  before.  Her 
menstruation  had  been  absent  ever  since,  but  there  had  been 
a  vicarious  flow  regularly  from  her  nose.  The  abdomen  steadily 
and  rapidly  enlarged  and  the  woman  was  firmly  convinced  that 
she  was  pregnant.  With  this  idea  she  obtained  admission  to  the 
maternity  wards  of  the  Philadelphia  Hospital,  having  been  pre- 
viously examined  by  a  physician  who  pronounced  her  pregnant  at 
term.  The  abdominal  distention  was  due  entirely  to  tympanites, 
the  result  of  partial  obstruction  of  the  sigmoid  flexure,  which  was 
involved  in  the  adhesions  of  the  uterine  appendages  on  the  left 
side. 


CHAPTER   VII. 
The  Pathology  of   the   Pregnant  Woman* 

DISEASES  OF  THE  GENITALIA. 

Displacements  of  the  Pregnant  Uterus, — The  uterus  in 
pregnancy  may  be  displaced  forward,  backward,  to  either  side, 
or  downward.  It  may  form  part  of  the  sac  contents  in  inguinal 
and  ventral  herniae,  and  it  may  be  twisted  upon  its  pedicle,  the 
cervix. 

Anteflexion  of  the  Gravid  Uterus. — Usually  the  growth  of  the 
uterus  upward  into  the  abdominal  cavity  corrects  the  anteflexion 
spontaneously,  but  if  it  is  bound  down  by  bands  of  adhesion 
the  result  of  pelvic  inflammation,  or  the  consequence  of  anterior 
fixation  of  the  uterus  by  an  abdominal  or  vaginal  operation,  pain 
in  the  uterus  and  difficulty  in  urination  result,  until  finally 
the  uterus  expels  its  contents  or  forces  its  way  up  into  the 
abdominal  cavity.  A  number  of  cases  have  been  observed  of  late 
years  in  which,  after  an  anterior  fixation  of  the  uterus,  the  uterine 


2l6  PREGNANCY. 

cavity  enlarged  solely  by  the  distention  of  the  posterior  uterine 
wall,  the  fundus  and  anterior  wall  much  thickened,  remaining  at 
the  level  of  the  pelvic  brim. 

Treatment. — Pelvic  massage,  tampons,  and  digital  pressure 
upward  through  the  anterior  vaginal  vault  may  stretch  or  break 
the  adhesions  and  allow  the  uterus  to  ascend  normally  into  the 
abdominal  cavity.  An  abdominal  section  and  the  severance  of  ad- 
hesions may  be  justifiable.  Late  in  gestation  the  whole  body  of 
the  uterus  may  fall  forward,  producing  a  pendulous  abdomen,  in 
consequence  of  greatly  relaxed  abdominal  walls  ;  diminution  in 
the  length  of  the  abdominal  cavity,  as  in  kyphosis  ;  prevention 
of  the  entrance  into  the  pelvis  of  the  presenting  part,  as  in  a 
rachitic  pelvis  ;  or  by  reason  of  an  exaggerated  separation  of  the 
recti  muscles.  This  anterior  displacement  is  treated  by  an  abdom- 
inal binder,  not  tight  enough  to  increase  the  intra-abdominal  pres- 
sure injuriously,  but  firm  enough  to  aft'ord  support  (Figs.  152-155). 

Retroflexion  or  Retroversion.  —  Retrodisplacement  is  of  fre- 
quent occurrence.  It  is  explained  almost  invariably  by  the  pre- 
\-ious  existence  of  a  backward  displacement,  although  an  acute 
retrodisplacement  of  the  uterus  may  occur  in  the  first  {^^ 
months  of  pregnancy  from  the  same  causes  that  determine  such 
an  accident  at  other  times.  A  persistent  retrodisplacement  of 
the  gravid  uterus  is  more  common  in  contracted  than  in  normal 
pelves,  especially  if  the  promontory  is  prominent.  The  dis- 
placement is  more  frequently  a  retroflexion  than  a  retroversion. 

Symptoms. — The  earliest  and  most  distincti\'e  s\^mptoms  are 
a  gradually  increasing  c/j'-w/r/V?,  and  distention  of  the  bladder,  with 
possibh'  the  overflow  of  retention,  though  there  ma}-  have  been 
backache,  pelvic  pain,  and  a  discharge  of  blood  prior  to  the 
mechanical  obstruction  of  the  neck  of  the  bladder  and  the 
urethra.  Occasionall\-  the  dysuria  appears  suddenl}'  after 
straining  at  stool  or  other  effort  that  increases  intra-abdominal 
pressure.  The  presence  of  any  of  these  symptoms  indi- 
cates an  immediate  vaginal  examination,  whereupon  the  cervix  is 
found  just  behind  and  perhaps  above  the  symphysis,  the 
body  of  the  uterus  distends  Douglas's  pouch,  and  may  push 
the  posterior  vaginal  wall  forward  and  downward  to  the 
vulvar  orifice.  In  neglected  cases,  or  if  the  displacement 
is  not  spontaneously  corrected,  incarceration  occurs.  By 
this  term  is  meant  the  imprisonment  of  the  growing  uterus 
in  the  pelvic  cavity,  where  growth  beyond  a  certain  point  is 
impossible.  The  bladder  and  bowels  are  so  compressed  that 
they  may  become  gangrenous,  and  the  pressure  to  which  the 
uterus  is  subjected  leads  to  congestion,  inflammation,  and  gan- 
grene.     The    symptoms    of   this   condition   manifest   themselves 


DISEASES    OF   THE    GENITALIA. 


217 


■ 

f 

T 

H 

r 

f] 

M 

H 

r  H 

^ 

^^^M:-^ 

^^H 

&./  \ 

^^H 

1 

1^ 

">« 

\J 

Figs.  152-155. — This  abdominal  supporter  was  designed  by  a  mechanical  int,'!- 
neer,  T.  S.  Patterson,  M.  E.  It  proved  so  efficient  that  I  recommend  it.  A-B 
shows  the  faulty  lines  of  support  of  the  ordinaiy  supporters ;  C-D,  the  jiroper  lines 
of  support. 

Old  Method. — If  five  pounds'  pressure  is  to  be  relieved  at  this  point  (A)  by  the 
old  method,  it  will  create,  due  to  leverage,  approximately  a  pressure  equal  to  five  or 
six  times  the  original  five  jwunds'  jjiessure  at  location  B,  as  B  is  one-fifth  to  one-sixth 
the  distance  from  spine  E  as  A  is  from  spine  E.  ' 

New  Method. — Pressure  to  be  relieved  at  location  C  is  conveyed  without  being 
multiplied  in  a  straight  line  to  spinal  column  E,  at  location  D,  where  the  pressure  is 
more  easily  carried. 


2l8  PREGNANCY. 

after  the  third  month,  often  in  the  fifth,  and  sometimes  as  late 
as  the  sixth  month.  They  are  :  Occlusion  of  the  bowel  and 
urethra,  with  their  associated  symptoms  ;  congestion,  inflamma- 
tion, and  suppuration  of  the  uterus,  which  may  finally  slough 
with  the  development  of  peritonitis,  septicemia,  or  pyemia. 

Terfninations  of  Retrodisplacevients  when  Artificial  Means 
are  Not  Employed  to  Correct  the  Displacement. — Spontaneous 
reposition  occurs  in  the  majority  of  cases,  though  it  should 
not  be  awaited  in  practice.  It  is  more  likely  in  retroflexion 
than  in  retroversion ;  ^  spontaneous  abortion  does  not  occur  so 
frequently  as  one  might  expect,  on  account  of  the  mechan- 
ical difficulty  of  emptying  the  uterus.  In  115  cases  abortion 
occurred  in  only  5  (Hermann).  If  abortion  occurs  in  conse- 
quence of  retrodisplacement  of  the  uterus  it  is  usually  early  in  the 
second  or  third  month;  incarceration  is  the  termination  which  the 
physician  must  have  in  mind  as  always  possible,  and  against 
which  effective  preventive  treatment  must  always  be  adopted  ; 
expulsion  of  the  uterus  from  the  body  as  a  lahole  through  a  rent 
in  the  posterior  vaginal  wall  is  an  effort  on  the  part  of  nature  to 
correct  an  impossible  condition  of  affairs,  but  it  can  obviously  be 
only  partially  successful.  Rarely  the  disadvantages  and  dangers 
of  posterior  displacement  of  the  pregnant  uterus  are  overcome 
by  '' saccidation  of  tlie  uterus''  In  this  condition  the  fundus 
and  posterior  wall  of  the  uterus  remain  deep  within  the  pelvis, 
while  the  growing  fetal  body  is  accommodated  by  an  enormous 
distention  of  the  anterior  uterine  wall. 

Prognosis. — The  outlook  is  always  satisfactory  as  regards 
maternal  life  if  appropriate  treatment  is  adopted  early.  If 
the  condition  is  overlooked  or  neglected,  death  frequently  occurs. 
In  fifty-one  fatal  cases  the  following,  in  order  of  frequency,  were 
the  causes  of  death  :  Uremia  and  exhaustion,  rupture  of  the 
bladder,  septicemia,  peritonitis  from  inflammation  of  the  bladder, 
pyemia,  rupture  of  the  peritoneum  and  of  the  vagina,  errors  in 
treatment,  and  gangrene  of  the  colon. 

Treatment. — The  appropriate  treatment  is  reposition.  If 
the  attempt  is  made  early,  manipulation  will  succeed.  The 
bladder  should  first  be  emptied  by  a  catheter.  Its  distention 
may  be  enormous.  It  may  reach  above  the  navel  and  may 
contain  more  than  6  quarts  of  urine."     If  the  distention  of  the 

1  Even  with  firm  adhesions  of  long  standing  binding  the  uterus  firmly  backward 
I  have  seen  spontaneous  reposition  take  place. 

2  Fritsch  reports  a  case  with  3320  grams.  Veit's  "  ITandbuch  der  Gynak.," 
vol.  ii.  In  the  University  Maternity  we  have  withdrawn  by  the  catheter  in  fourteen 
hours  270  ounces  of  urine  in  a  case  of  retroflexed  gravid  womb.  In  another  case  in 
the  Philadelphia  Hospital  244  ounces  were  drawn  in  twenty-four  hours.  A  short  glass 
catheter  should  never  be  used  in  these  cases.  A  long  silk,  metal,  linen,  or  soft-rubber 
catheter  is  preferable. 


DISEASES   OF  THE    GENITALIA. 


219 


bladder  is  extreme,  the  whole  amount  of  urine  should  not  be 
drawn  ofif  at  once.  The  sudden  reduction  of  intravesical  pres- 
sure has  been  followed  by  a  fatal  hemorrhage  from  the  vesical 
mucosa.  The  patient  being  placed  in  the  lithotomy  position,  the 
fundus  uteri  is  pressed  upward  by  two  fingers  in  the  posterior 
vaginal  vault  in  the  direction  of  one  or  the  other  sacro-iliac  joint 
to  avoid  the  projecting  promontory  of  the  sacrum.  Failing  in 
this  attempt,  the  patient  should  be  placed  in  the  knee-chest  pos- 
ture and  a  repositor  used  to  press  upon  the  fundus.  An  anes- 
thetic is  always  useful  in  difficult  cases. 

If  the  knee-chest  pos- 
ture fails,  and  there  is  no 
obstruction  from  an  over- 
filled bladder,  the  cervix 
should  next  be  drawn 
downward  with  a  tenacu- 
lum, while  at  the  same 
time  pressure  is  made  up- 
ward and  to  one  side  upon 
the  fundus.  If  the  at- 
tempts at  reposition  are 
successful,  as  they  almost 
always  are,  a  large-sized 
pessary  should  be  applied 
until  the  growth  of  the 
organ  maintains  it  in  the 
abdominal  cavity,  and  its 
increased  size  prevents  its 
slipping  back  under  the 
promontory.  The  artifi- 
cial support  should  be 
removed  midway  between 
the  third  and  f  o  u  r  t  h 
months.  If  the  uterus 
is  bound  down  by  strong 

inflammatory  bands,  steady  and  long-continued  pressure  should 
be  applied  by  means  of  large  tampons  in  the  posterior  vaginal 
vault,  inserted  while  the  patient  is  in  the  knee-chest  posture,  by 
the  aid  of  a  Sims  speculum,  and  renewed  daily.  A  colpeuryntcr 
inserted  in  the  Sims  position,  distended  and  allowed  to  remain 
for  twenty-four  hours,  has  succeeded  when  other  plans  have  failed. 
FaiHng  to  secure  reposition  by  these  measures  abortion  should  be 
induced,  before  the  symptoms  of  incarceration  appear. 

Treatment  of  Retrodisplaceuient  when  the  Uterus  is  Incareer- 
ated. — The   physician's  attention   must   first   be  directed   to   the 


Fig.  156. — Frozen  section  of  retroverted 
uterus  of  three  and  a  half  to  four  months.  Death 
from  rupture  of  bladder. 


220  PREGNANCY. 

overfilled  bladder.  Catheterization  is  usually  easy  if  a  prostatic 
catheter  is  employed  and  if  the  physician  recollects  that  the  lower 
segment  of  the  bladder  as  well  as  the  urethra  is  enormously 
stretched  and  compressed/  making  of  the  latter  a  canal  perhaps 
more  than  five  inches  long  (Fig.  156).  A  long  flexible  or  semi- 
stiff  catheter  may  be  tried  if  the  prostatic  catheter  cannot  be  in- 
troduced. If  the  insertion  of  the  catheter  is  difficult,  the  cervix 
may  be  caught  with  a  tenaculum  and  pulled  backward,  as  suggested 
by  Cohnstein,  so  as  to  relieve  the  pressure  upon  the  urethra.  If 
catheterization  is  impossible,  suprapubic  puncture  of  the  bladder 
with  an  aspirating  needle  is  always  practicable  and  perfectly  safe 
if  done  in  an  aseptic  manner.  After  the  bladder  is  emptied  at- 
tempts at  reposition  should  be  made  as  previously  described.  If 
these  attempts  fail,  abortion.  m_ust  be  induced.  If  it  is  impossible 
to  effect  an  entrance  into  the  cervix  for  this  purpose,  it  is  justi- 
fiable to  puncture  the  uterine  wall  through  the  vaginal  vault,  and 
thus  draw  off  the  liquor  amnii.  The  uterus  may  now  respond  to 
efforts  at  replacement,  or  it  may  be  possible  to  draw  down  the 
cervix  and  to  dilate  its  canal,  to  make  feasible  the  evacuation  of 
the  uterine  contents.  As  a  last  resort,  vaginal  hysterectomy  is 
justifiable.  It  is,  indeed,  the  operation  of  election  if  the  walls 
of  the  uterus  are  badly  inflamed,  have  begun  to  suppurate,  or 
are  gangrenous.  If  the  case  is  in  the  hands  of  an  expert  ab- 
dominal surgeon,  cehotomy  is  recommended  before  resorting 
to  the  induction  of  abortion,  for  the  purpose  of  replacing  the 
uterus  by  direct  intrapelvic  manipulation.^ 

Lateral  displacements  include  lateroposition,  lateroversion, 
and  lateroflexion.  Lateroposition  is  usually  a  congenital  de- 
fect, due  to  an  abnormally  short  broad  ligament,  placing 
the  whole  uterine  body  more  .to  one  side  of  the  abdominal 
cavity  than  the  other.  Lateroflexion  is  also  congenital,  due 
to  imperfect  development  of  one  side  of  the  uterine  body,  so 
that  the  imperfectly  developed  side  acts  like  the  string  of  a 
bow  and  bends  the  sound  side  on  itself.  Lateroversion  is  a 
tilting  of  the  fundus  to  one  side.  Right  lateroversion  is  the 
rule  during  pregnancy.  These  malpositions  of  the  uterus  com- 
plicate labor  more  than  pregnancy  (see  Dystocia). 

Prolapse  of  the  Gravid  Uterus. — The  causes  of  this  displace- 

1  Reed,  "Am.  Tonrn.  Obstet.,"'  1904,  claims  that  tlie  inability  of  the  bladder 
to  empty  itself  depends  upon  a  paralysis  of  its  nerve  supply.  The  Scotch  verdict  of 
"  not  proven  "  must  still  apply  to  this  theory. 

•^  Ilermann,  "  Br.  Med.  Journ.,"  April  16,  1904,  claims  that  the  bladder  alone 
need  be  attended  to;  that  in  90  per  cent,  of  cases  tiie  retroflexion  will  right  itself  if 
the  bladder  is  kept  empty.  Even  if  this  statement  is  true  it  is  more  sensible  to  re- 
place the  uterus  after  emptying  the  bladder,  in  order  to  avoid  repeated  catheterization 
and  to  guard  against  a  possible  failure  of  spontaneous  reposition. 


DISEASES   OF   THE    GENITALIA. 


221 


ment  are:  Impregnation  in  an  organ  already  prolapsed;^  retro- 
version, relaxed  vaginal  walls  and  outlet,  and  the  increased 
weight  of  the  uterus  in  the  first  few  weeks  of  pregnancy;  violent 


Fig.    157. — Inversion   of  the  vagina  and  prolapse  of  tlie  cervix   in   a  woman  eight 

months  pregnant. 


straining  or  traumatism;   acute  edema  of  the  cervix;    a  tumor  in 
the  pelvis  pushing  the  uterus  downward. 

TJie  spo}itanco2is  tcnninations  are  :  Complete  spontaneous  re- 
position, which  is  most  frequent ;  incom[)lctc  reposition,  the 
uterus  continuing  in  a  state  of  partial  prolapse  to  full  term  ;  fail- 
ure of  retraction,  inducing  incarceration,  with  possible  gangrene 
of  the  uterus  ;  failure  of  retraction,  inducing  abortion,  which  is 

1  A  patient  in  my  wards  of  the  Philadelpliia  Hosjiital  had  liad  a  complete  pro- 
lapse for  years.  Copulation  had  occurred  by  means  of  an  enormously  dilated  cervical 
■canal  and  the  woman  had  been  impregnated  in  this  manner.  There  was  a  sponta- 
neous reposition  of  the  womb  before  the  third  month  of  pregnancy. 


222  PREGNANCY. 

most  likely  to  occur,  as  there  is  no  mechanical  obstacle  to  the 
escape  of  the  uterine  contents.  Pregnancy  will  not  continue  to 
term  in  a  completely  prolapsed  uterus. 

Treatment. — The  appropriate  treatment  of  a  prolapsed  gravid 
uterus  is  reposition  after  emptying  the  bladder  and  bowels  and 
in  the  knee- chest  posture,  followed  by  the  insertion  of  a  globe 
pessary,  retained  by  a  firm  T-bandage.  If  the  uterus  is  incar- 
cerated, attempts  at  reposition  should  be  cautiously  made,  but 
if  they  fail,  owing  to  adhesions  and  edema,  abortion  should  be 
induced  and  the  organ  then  replaced.  If  the  uterus  is  infected 
it  should  be  removed  by  a  vaginal  hysterectomy.  If  reposition  is 
impossible  owing  to  the  presence  of  a  tumor,  vaginal  or  abdominal 
section  is  indicated  to  remove  the  tumor.  These  operations  may 
also  be  required  if  reposition  is  prevented  by  adhesions. 

The  Pregnant  Uterus  forming  a  Part  of  a  Hernial  Protrusion. — ■■ 
This  displacement  occurs  very  exceptionally  in  inguinal  and  ven- 
tral, but  never  in  crural,  hernia,  the  uterus  falling  into  the  sac 
before  or  after  impregnation.  The  ventral  variety  is  most  frequent, 
and  may  occur  between  abnormally  separated  recti  muscles,  or, 
more  rarely,  is  seen  on  the  lateral  aspect  of  the  abdomen.  When 
it  is  associated  very  exceptionally  with  inguinal  hernia,  the  preg- 
nancy is  apt  to  be  in  one  horn  of  an  abnormally  developed  uterus. 

Treatment. — There  should  be  an  attempt  at  reposition.  Fail- 
ing in  this,  the  cervix  may  be  dilated  and  the  hand  inserted  in 
the  uterus,  to  perform  version  and  extraction.  The  emptied  uterus 
may  then  be  returned  to  the  abdominal  cavity.  The  last  resort 
is  Cesarean  section  or  amputation  of  the  pregnant  uterus. 
Winckel  has  reported  such  a  case,  with  a  successful  issue. 

Torsion. — A  slight  degree  of  torsion  from  left  to  right  is 
physiological  and  constant.  A  more  exaggerated  degree  may 
be  due  to  some  abnormal  condition,  usually  inflammatory,  near 
the  uterus,  which  results  in  twisting  it  upon  its  longitudinal  axis. 
An  ovary  may  thus  be  brought  in  front  and  may  be  subjected 
to  traumatism  during  manipulation  of  the  abdomen.  Extreme 
torsion  of  the  pregnant  uterus  with  lateral  displacement  has  led 
to  a  mistaken  diagnosis  of  extra-uterine  pregnancy. 

DISEASES  OF  THE  UTERINE  MUSCLE. 

Rheumatism  of  the  myometrium  is  rare,  but  is  occasion- 
ally observed  in  women  of  rheumatic  diathesis. 

Symptoms. — Great  pain,  localized  in  the  uterine  walls,  lasting 
throughout  the  latter  months  of  pregnancy,  and  increased  periodi- 
cally by  the  intermittent  uterine  contractions.  There  may  be  a 
subacute  fever.  The  therapeutic  test  is  the  most  valuable  factor 
in  the  diagnosis. 


DISEASES   OF   THE    UTERINE   MUSCLE. 


22.1 


Treatment. — The  administration  of  salicylates  is  immediately 
effectual. 

Metritis  is  almost  invariably  acquired  before  impregnation. 
The  disease  exercises  a  most  deleterious  influence  upon  gesta- 
tion, giving  rise  to  a  sensation  of  weight  and  heaviness  in  the 
pelvis,  to  an  exaggeration  of  the  reflex  disturbances  of  pregnancy, 
and  often  resultino-  in  abortion. 


Fig.  158. — Fibromyoma  and  three  and  one-half  months'  fetus. 

(Author's  case.) 


Hysterectomy. 


Treatment. — Glycerin  tampons  may  be  packed  in  the  vaginal 
vault  to  support  the  womb  and  to  deplete  it,  although  the  treat- 
ment is  very  likely  to  induce  abortion. 


New  growths  complicate  labor  rather  than  gestation. 

Fibromyomata  grow  rapidly  on  account  of  the  increased 
blood-supply  to  the  genitalia,  and  in  exceptional  cases  some 
operative  interference  is  demanded  for  the  pain  and  pressure 
symptoms.  In  the  majority  of  cases  no  treatment  is  required  in 
pregnancy.  Pinard  ^  observed  84  cases  of  myoma  in  14,000 
pregnancies  in  the  Baudelocque  clinic.  In  66  pregnancy  was 
undisturbed;  in  13  there  was  premature  labor;  in  5  abortion;  in 
4  cases  intervention  was  necessary.  I  have  been  obliged  to  do 
myomectomy  twice  in  pregnancy  on  account  of  excessive  pain, 
to  perform  hysterectomy  twice  in  the  fourth  month  of  gestation  on 
account  of  pressure  symptoms  and  kidney  breakdown,  and  to  per- 

*  "Ann.  de  Gyn.,"  Sept.,  1901. 


224 


PREGNANCY. 


Fig.    159. — A  fibromyoma  of  the  round  ligament  in   the   inguinal   canal.      Weight, 

6J  ounces. 


Fig.  160. — Fibromyoma    of    the   right  round   ligament    in   the   inguinal  canal    in  a 
woman  pregnant  at  term. 

form  Cesarean  section  at  seven  and  one-half  months,  because  of 
the  embarrassment  of  heart  action  and  respiration  due  to  the 
enormous  distention  of  the  abdomen. 


DISEASES    OE   THE    CERVEX.  225 

Fihromyomata  oj  the  round  ligament  in  the  groin  rarely  develop 
to  a  considerable  size  in  consequence  of  the  stimulus  of  pregnancy. 
They  must  be  removed  by  an  extraperitoneal  operation  after 
delivery.  I  have  operated  on  three  patients  for  this  condition 
(Fig.  158  is  a  good  example). 

Ovarian  cysts,  especially  dermoids,  may  grow  rapidly  in  preg- 
nancy, occasionally  giving  rise  to  such  severe  pain  that  ectopic 
gestation  is  suspected.  The  pedicle  may  be  twisted  and  the 
tumor  becomes  gangrenous.  There  is  usually  an  entire  absence 
of  subjective  symptoms,  except  an  uncomfortable  distention  of  the 
abdomen,  till  the  onset  of  labor  or  the  puerperium.^  Ovarian 
tumors  should  always  be  removed  during  early  pregnancy  if  pos- 
sible. The  danger  of  the  operation  is  no  greater  than  at  other 
times,  and  the  proportion  of  miscarriages  is  scarcely  increased 
above  the  average  in  all  pregnant  women  (20  per  cent.). 

Diseases  of  the  Cervix. — The  inflammatory  diseases  of  the 
cervix  may  exaggerate  the  reflex  disturbances  of  pregnancy. 
Endocervicitis  and  interstitial  cervicitis  are  found  in  too  many 
cases  of  hyperemesis  to  be  a  mere  coincidence.  An  annoying 
leukorrhea  during  pregnancy  may  have  its  origin  in  the  cervical 
canal.  Exacerbations  of  the  inflammation  may  give  rise  to  bloody 
discharges,  especially  at  times  corresponding  to  the  menstrual 
period.  Supposed  menstruation,  persisting  throughout  preg- 
nancy, has  thus   been  accounted  for. 

Treatment. — Applications  of  nitrate  of  silver  solution,  poured 
into  a  cylindrical  speculum,  give  the  best  results  in  endocervi- 
citis. Congestion,  inflammation,  and  hypertrophy  of  the  cervix 
are  best  treated  by  rest  in  bed  and  applications  of  glycerol  of 
tannin  tampons.  All  local  treatment  of  the  cervix,  however 
mild,  increases  somewhat  the  risk  of  miscarriage.  The  patient 
should  be  informed  of  this  fact  and  her  consent  should  be  ob- 
tained before  the  treatment  is  begun. 

Cervical  polyps  and  interstitial  cervical  myomata  shoukl  be 
removed  before  labor  begins;  the  former  by  ligation  and  section 
of  the  pedicle,  the  latter  by  enucleation  (Fig,  161). 

Acute  edema  of  the  cervix  is  due  either  to  obstructed  circula- 
tion or  to  an  angioneurosis.  It  is  very  rare.  Only  11  cases  arc 
recorded.'^ 

Cancer  of  the  cervix  is  rare  in  pregnancy:  in  57,833  laI:)ors  it 
was  observed  but  26  times  (i  in  2000).^     With  very  few  excep- 

1  For  the  statistics  of  the  child-bearing  process,  Cdmjilicated  by  pelvic  and  :\h- 
dominal  tumors,  see  Dystocia. 

'^  Seitz,  "  Zentralbl.  f.  (iyn.,"  No.  lo,  1905. 

*  Sarwey,  "  Veit's  Handlmch,"  ill,  2,  489,  1899.  See  also  Ilense,  "  Zeitsch.  f. 
Geb.,"  Bd.  xlvi,  page  68.  Werthelm,  Winckel's  "  Handbuch  der  Geb.,"  2'^,  p.  474. 
15 


226 


PREGNANCY. 


tions  it  is  found  in  women  who  have  borne  many  children  before 
(on  the  average,  7).  The  subjective  symptoms  are  bleeding, 
foul  discharge,  and  pain.  The  well-known  objective  signs  are 
obtained  by  a  specular  and  digital  examination.  It  is  a  common 
mistake  to  overlook  the  existence  of  pregnancy  before  the  third 
month  in  carcinoma  of  the  cervix.  The  proportion  of  abortions 
is  raised  by  this  complication  to  30  or  40  per  cent.  Missed  labor 
has  been  reported  several  times  ;  also  spontaneous  rupture  of  the 
uterus ;  placenta  prjevia  is  frequently  found  associated  with  a  can- 
cerous cervix.  The  existence  of  pregnancy  hastens  the  progress 
and  widens  the  extent  of  the  disease  in  a  remarkable  manner. 
The  prognosis  is  unfavorable :  eight  per  cent,  die  undelivered,  and 
43  per  cent,  die  during  or  directly  after  labor  (Sarwey). 


Fig.  161. — Mucous  polyps  of  the  cervix. 


.  If  the  condition  is  operable  when  discovered,  the  uterus 
should  be  extirpated,  preferably  by  the  vaginal  route,  which  is 
always  practicable  for  the  first  four  months.  Twenty-nine  such 
operations  have  been  collected  without  a  single  death.  Diihrs- 
sen  has  proposed  the  evacuation  of  the  uterus  by  the  vaginal  route 
after  the  fourth  month,  if  necessary,  by  freeing  the  cervix  from 
the  vagina  and  splitting  the  anterior  uterine  wall,  rupturing  the 
membranes,  and  extracting  the  uterine  contents,  and  then  finishing 
the  operation  by  the  vaginal  extirpation  of  the  emptied  womb. 
This  procedure,  he  claims,  is  practicable  at  term.^  It  is  preferable, 
however,  to  perform  a  combined  or  an  abdominal  panhysterectomy 

1  "  Der  vaginale  Kaiserschnitt,"  Berlin,  1S96  ;  and  "  Ueber  die  Behandlung 
des  Uteruscarcinoma  in  der  Schwangerschaft,"  "  Centralbl.  f.  Gyn.,"  1S97,  No.  30, 
p.  942. 


DISEASES   OF  THE    VAGINA.  22/ 

in  the  later  months,  associated  with  a  Cesarean  section,  if  the 
fetus  is  viable.  In  operable  cases  the  fetus  should  receive  no  con- 
sideration. In  inoperable  cases  it  is  better  to  await  the  viability 
of  the  child,  and  then  to  deliver  it  if  necessary  by  abdominal  or  vagi- 
nal Cesarean  section. 

Diseases  of  the  vagina  are  due  to  an  increased  blood-sup- 
ply or  to  infection. 

Vaginal  leukorriiea  is  frequently  an  annoying  complication  of 
pregnancy.  Granidar  vaginitis  is  usually  found  to  be  the  cause, 
and  there  are  quite  often  single  spurs  of  condyloma  growing 
from  the  vaginal  mucous  membrane.  In  very  rare  instances  large 
masses  of  venereal  warts  may  grow  from  the  cervix,  the  vaginal 
vault  and  walls.  (Plate  9.)  These  masses  should  be  excised  in  the 
last  month  of  gestation,  by  ligating  the  pedicle  of  healthy  mucous 
membrane  with  catgut  and  cutting  them  off.  The  best  treat- 
ment of  vaginal  leukorrhea  is  a  single  application  of  a  thirty  per 
cent,  solution  of  carbolic  acid  in  glycerin.  The  application  is 
made  on  a  pledget  of  cotton  through  a  skeleton  wire  bivalve  or 
a  cylindrical  speculum.  It  should  be  followed  by  an  alcohol  and 
w^ater  douche.  The  buttocks  and  vulva  must  be  well  greased 
with  vaselin  to  prevent  a  carbolic  acid  burn.  An  easy  treatment 
for  the  patient  to  carry  out  herself  is  to  insert  at  bedtime  vaginal 
suppositories  of  the  milder  antiseptics  and  astringents  with  gly- 
cerin as  a  base.  A  boracic  acid  douche  is  taken  in  the  morning. 
Another  successful  plan  of  treatment  is  to  pour  into  a  cylindrical 
speculum  a  solution  of  nitrate  of  silver,  gr.  xx— f.5j,  then  to  with- 
draw the  speculum  slowly  so  that  successive  folds  of  vaginal 
mucous  membrane  are  bathed  in  it.  A  douche  of  weak  salt 
solution  should  follow  the  application. 

Specific  infection  with  the  gonococcus  should  cause  anxiety  on 
account  of  the  eyes  of  the  new-born  infant  and  the  infection  of  the 
mother  after  delivery,  even  should  there  be  no  great  discomfort 
during  pregnancy.  The  condition  requires  energetic  treatment. 
A  bichlorid  douche,  i  :  2000,  twice  daily,  and  tampons  dusted 
with  tannic  acid,  give  good  results.  For  the  bichlorid  douche,  a 
permanganate  of  potassium  solution,  f5j  :  Oij  (3.75:946  cc), 
every  three  hours,  may  often  be  substituted  with  advantage,  and 
for  the  tannin  tampons  pledgets  of  cotton  saturated  with  a  5 
per  cent,  solution  of  argyrol.  The  vulva  should  be  thoroughly 
washed  with  pledgets  of  cotton,  tincture  of  green  soap,  and  hot 
water  at  least  once  a  day,  followed  by  an  irrigation  of  the  vulva 
with  permanganate  solution  poured  out  of  a  ])itcher. 

Pathogenic  Micro=organisms  in  the  Vagina. — A  studvof  the 
vaginal  flora  during  pregnancy,  begun  by  Conner  and  Doderlcin, 


228 


PREGNANCY. 


has  thrown  additional  Hght  on  the  question  of  septic  infection  after 
labor.  In  the  normal  secretions,  especially  of  virgins,  there  is  a  large 
nonpathogenic  bacillus,  which  seems  to  have  a  destructive  action 
upon  other  micro-organisms  by  producing  an  intensely  acid  environ- 
ment (probably  due  to  lactic  acid).  In  pathological  secretions  the 
reaction  is  weakly  acid,  neutral,  or  alkaline;  there  is  also  in  patho- 
logical secretions  an  increased  amount  of  mucus,  bubbles  of  gas, 
epithelial  cells,  and  a  large  number  of  mixed  micro-organisms. 
Out  of  195  pregnant  women  examined  by  Ddderlein,  44.6  per 
cent,  had  pathological  secretions.  There  is  great  diversity  of 
opinion  among  those  who  have  investigated  the  subject  as  to  the 
presence  of  disease  germs  in  the  vagina,  such  as  streptococci, 
colon  bacilh,  and  the  streptococci.  No  one  denies  that  these 
micro-organisms  may  be  found  on  the  vulva.  It  needs  only 
common  sense  to  admit  that  they  must  often  be  introduced  into 
the  vagina.     Lack  of  personal  cleanliness,  coitus,  a  gaping  vulvar 


Fig.  162. — Emphysematous  colpitis  (Gebhard). 

orifice,  favor  an  ascending  infection.  Clinical  experience,  more- 
over, should  convince  any  one  of  this  possibility  (see  Puerperal 
Infection). 

Colpohyperplasia  cystica  is  an  infectious  disease  of  the  vaginal 
mucous  membrane  in  pregnancy,  described  by  Winckel,  in  which 
little  retention  cysts  are  scattered  throughout  the  hypertrophied 
mucous  membrane  in  the  interstices  of  the  submucous  connective 
tissue.     In  rare  cases  the  fluid  disappears  from  the  cysts  and  its 


DISEASES   OF   THE    VAGINA. 


229 


place  is  taken  by  gas  {colpitis  emphysematosa) ,  which  Zweifel  has 
demonstrated  to  be  trimethylamin.  If  the  vesicles  are  pricked 
they  do  not  refill.  This  treatment,  with  a  mild  antiseptic  douche 
(boracic  acid),  may  be  indicated.  The  disease  disappears  of 
itself  after  delivery.  It  has  been  ascribed  by  Eisenlohr  to  a 
short,  unidentified  bacillus,  by  Lindenthal  to  a  bacillus  emphy- 
sematosus  vaginas. 

Mycosis  of  the  vagina  may  be  due  to  the  leptothrix  vaginaHs 
or  to  oidium  albicans.  The  vaginal  mucous  membrane  is  red- 
dened and  at  intervals  displays  patches  of  white  membrane  hke 
thrush  in  the  mouth  of  an  infant.  Another  form  of  parasitic 
vaginitis  is  due  to  the  trichomonas  vaginalis.  The  cause  of 
these  inflammations  may  be  detected  by  microscopic  examina- 
tion and  they  are  easily  curable  by  boracic  acid  douches  and 
cleanliness. 


Fig.   163. — Hypertrophy  of  the  urethral  walls  in  pregnancy  (author's  case). 

Varices  of  the  vagina  may  be  dangerous  if  the  veins  are  large 
and  their  walls  thin.  The  part  should  be  guarded  from  trau- 
matism, which  might  result  in  rupture  of  the  distended  veins  and 
an  alarming  if  not  a  fatal  hemorrhage. 

Polypoid  hypertrophies  of  the  vaginal  mucous  membrane,  usu- 
ally at  the  site  of  the  cariinculae  myrtiformes,  may  attain  con- 
siderable size,  causing  discomfort  during  pregnancy,  and  possibly 
obstructing  the  canal  in  labor.  ■  I  have  seen  one  case  of  such 
enormous  hypertroi)hy  of  the  tissues  surrounding  the  meatus 
urinarius  that  the  urethra  completely  filled  the  vaginal  entrance 
(Fig.  163). 


230 


PREGNANCY. 


Fig.   164. — Vaginal  cyst. 


i% 


Fig.  165. — Primaiy  carcinoma  of  vagina. 

Suburethral  abscess  is  an  accumulation  of  pus  in  the  anterior 
vaginal  wall,  bulging  out  at  the  vulvar  orifice  like  a  cystocele, 
and  on  pressure  discharging  the  pus  slowly  and  imperfectly  into 


DISEASES    CF   THE    VULVA. 


231 


the  urethra  through  the  opening  of  Skene's  glands.  The  abscess 
should  be  opened  through  the  vagina.^ 

Vaginal  cysts  (Fig.  164)  grow  larger  in  pregnancy,  but  they 
should  not  be  operated  on,  as  the  hemorrhage  is  formidable  and 
the  operation  may  interrupt  gestation.  They  may  be  punctured 
in  labor  and  removed  at  the  end  of  puerperal  convalescence. 

Cancer  and  sarcoma  of  the  vagina  (Figs.  165,  169),  if  operable, 
should  be  operated  upon,  regardless  of  the  pregnancy,  by  enu- 
cleation of  the  vagina  and  by  hysterectomy.  If  inoperable,  a 
Cesarean  section  is  indicated  when  the  fetus  is  viable. 


The  diseases   of  the   vulva  are   congestions,  hypertrophies, 
neoplasms,  or  infection. 


Fig.  166. — A  mass  of  pointed  condylomata  protruding  from  the  anus.     Removed 
by  the  electrocautery  clamp  ten  days  post-partuin. 

Varices  in  the  labia  majora  may  attain  a  large  size.  They 
have  been  ruptured  by  muscular  strain  in  an  effort  to  preserve 
the  equilibrium,  by  sitting  down  violently  upon  a  hard  substance, 
or  by  a  kick.  The  hemorrhage  is  always  dangerous,  and  has 
proved  fatal. 

Vegetations,   pointed  condylomata,   or   venerea!  warts    of  the 

vulva  may  reach  excessive  size  in  pregnancy.      They  arc  likely  to 

give  rise  to  an   irritating,  foul  secretion.      It  is  often  possible  to 

excise  the  growths.     Profuse  hemorrhage,  however,  is  to  be  feared, 

1  "Archives  de  Tocol.,"  Oct.,  1894. 


232 


PREGNANCY. 


Fig.  167. — Epithelioma  of  vulva. 


Fig.  168. — Inoperable  epithelioma  of  vulva. 


DISEASES   OF    THE    VULVA 


233 


and  the  operation  might  terminate  pregnancy.  An  antiseptic  and 
astringent  dusting-powder  is  a  good  palhative  treatment  until  the 
Avoman  is  dehvered,  when  the  growths  should  always  be  excised. 

Sarcomata  and  carcinomata  of  the  vulva,  if  operable,  should 
be  removed  with  the  inguinal  glands  regardless  of  the  pregnancy. 
If  inooerablCj  Cesarean  section  is  indicated  when  the  child  is  viable. 


Sarcoma  of  left  labium  minus. 


Pruritus  vulvae  may  be  a  neurosis  or  may  be  due  to  irritating 
vaginal  discharges  ancl  to  glycosuria.  The  disease  is  oftentimes 
most  intractable  to  treatment.  Antiseptic  vaginal  injections  may 
be  tried,  or  a  wash  of  2  per  cent,  solution  nitrate  of  silver  (Zweifel); 
menthol  ointment,  and  other  analgesic  applications  may  be  ap- 
plied; very  hot  water,  vinegar,  and  an  infusion  of  tol)acco  are 
household  remedies  of  some  value.  The  best  single  remedy  I  have 
found  is  a  strong  solution  of  carbolic  acid  in  cream  (f.^ss  to  f.sj), 
followed  by  cold  cream.  In  the  worst  cases  the  woman  becomes 
almost  maniacal.  She  may  walk  the  floor  all  night,  tearing  the 
vulva  with  her  fingernails  until  the  labia  are  raw  and  her  fingers 
are  stained  with  blood.  In  such  cases  the  induction  of  labor  must 
be  considered.     If  the  pruritis  persists  after  delivery  and  resists  all 


234 


PREGNANCY. 


medicinal  treatment,  the  excision  of  the  five  pairs  of  vulvar  nerves 
is  indicated. 

Edema  of  the  vulva  may  be  unilateral  or  bilateral,  and  in  some 
pregnant  women  reaches  an  extreme  degree.  It  is  due  to  the  pres- 
sure upon  the  pelvic  veins,  to  kidney  insufficiency,  or,  in  the  uni- 
lateral form,  to  labial  abscess.  There  are  some  women  who 
develop  a  vulvovaginal  abscess  regularly  in  every  pregnancy, 
and  not  at  other  times. 

Treatment. — If  the  cause  can  be  removed,  the  edema  disap- 
pears. The  treatment  of  kidney  insufficiency  removes  the 
dropsy  of  the  labia  associated  with  that  condition,  as  it  does 
the  other  dropsies  of  the  body.      If  the  edema  is  due  to  pressure, 


Fig.  170. — Venereal  warts  and  the  flat  condylomata  of  syphilis  combined. 

rest  in  bed,  with  the  occasional  assumption  of  the  knee-chest 
posture,  often  gives  relief.  If  the  edema  does  not  yield  to  gen- 
eral treatment  and  to  hot  fomentations  locally,  the  labia  may  be 
punctured.  It  should  be  remembered,  however,  that  even  this 
slight  operation  may  terminate  pregnancy.  The  vitality  of  the 
part,  moreover,  is  so  lowered  that  infection  and  even  gangrene 
may  follow  the  puncture.  In  the  unilateral  edema,  associated 
with  labial  abscess,  the  vulvovaginal  gland  should  be  laid  open 
in  the  last  month  of  pregnancy,  curetted,  cauterized  with  car- 
bolic acid,  and  packed  with  gauze,  or  else  should  be  exsected 
entirely,  which  is  the  safest  plan.  The  operation  is  bloody. 
Several  large  vessels  must  be  clamped  and  tied.      Otherwise  it  is 


DISEASES   OF   THE    VULVA. 


235 


not  difficult.  The  deep  wound  remaining  after  the  removal  of 
the  gland  is  united  with  interrupted  sutures.  A  drain  of  silk- 
worm-gut strands  must  be  laid  along  the  bottom,  and  allowed 
to  remain  at  least  forty-eight  hours.  Some  severe  infections  are 
due  to  the  rupture  of  a  vulvovaginal  abscess  during  labor. 


Fig.    171. — Varices  of  the  vulva  (author's  case). 

Periuterine  Inflammations  and  Adhesions. — Old  cases  of  pelvic 
adhesions  may  be  benefited  by  massage  and  tampons.  The  most 
satisfactory  results,  however,  are  secured  by  appropriate  treat- 
ment during  the  intervals  between  pregnancies.  Fresh  attacks  of 
periuterine  inflammation  in  pregnancy,  depending  upon  oopho- 
ritis and  pyosalpingitis,  are  exceedingly  dangerous.  Unlikely  as 
it  may  seem,  a  woman  may  be  impregnated,  though  she  have  at 
conception  a  pyosalpinx  and  densely  adherent  tubes  and  ovaries. 
The  inflammation  of  the  adnexa  may  be  lighted  up  afresh  by  the 
congestion  of  pregnancy.      In  such  cases  a  septic  peritonitis  may 


236 


PREGNANCY. 


be  averted  only  by  a  prompt  abdominal  section  and  the  removal 
of  the  appendages. 

Loosening  of  and  Pain  in  the  Pelvic  Joints. — If  the  normal 
relaxation  of  the  pelvic  joints  in  pregnancy  is  carried  to  an  ab- 
normal degree,  it  may  interfere  with  locomotion.  The  diagnosis 
is  made  by  a  vaginal  examination,  the  patient,  in  the  erect  pos- 
ture, taking  a  step  or  two,  while  the  examiner  holds  his  index- 
finger  in  the  vagina  against  the  posterior  surface  of  the  symphysis. 

Treatment. — Application  of  a  firm  binder  about  the  hips  will 
usually  make  the  patient  comfortable.  Rest  in  bed  may  be 
necessary  in  exaggerated  cases. 

The  pelvic  joints,  especially  one  sacro-iliac,  may  be  the  seat  of 
severe  pain  of  rheumatic  origin.  The  patient  may  be  entirely  dis- 
abled by  her  suffering.  This  pain  yields  immediately  to  antirheu- 
matic remedies  like  the  salicylate  of  strontium,  and  to  no  others. 


Fig.  172. — Edema  of  vulva  in  the  eighth  month  of  pregnancy,  due  to  pressure. 
Justominor  pelvis.  Fetal  head  unengaged  above  the  pelvic  brim.  Swelling  disap- 
peared in  a  few  hours  after  multiple  punctures  (University  Maternity). 

Breasts. — Mammary  Abscess. — Its  cause,  course,  and  treat- 
ment are  the  same  as  when  it  occurs  during  the  puerperium. 

Eczema  of  the  nipples  may  be  very  obstinate  in  its  resistance 
to  treatment.  Relief  may  only  be  secured  after  delivery.  Mean- 
while the  usual  treatment  for  eczema  may  be  tried  with  more  or 
less  success. 

Mammary  tumors  may  take  on  a  very  rapid  growth  under  the 
stimulus  of  pregnancy.  I  have  seen  a  simple  adenoma  the  size 
of  a  walnut,  quiescent  for  years,  reach  the  size  of  a  cocoanut 
during  pregnancy. 


DISEASES    OF   THE  ALIMENTARY  CANAL.  237 

DISEASES  OF  THE  ALIMENTARY  CANAL. 

Mouth. — Caries  of  the  teeth  frequently  troubles  a  pregnant 
woman.  It  is  a  common  saying  that  for  every  child  a  woman 
loses  a  tooth.  As  a  rule,  prolonged  and  painful  dental  opera- 
tions are  inadvisable  during  pregnancy.  Temporary  work  only 
should  be  done  by  the  dentist,  who  should  be  acquainted  with 
his  patient's  condition.  The  syrup  of  the  lactophosphate  of  lime. 
f  5  j  (3.75  c.c.)  t.  i.  d.,  internally,  a  mouth-wash  of  milk  of  mag- 
nesia, frequent  brushing  of  the  teeth,  and  rinsing  the  gums  with 
diluted  listerine  should  be  prescribed  for  all  pregnant  women  who 
display  a  tendency  to  dental  decay.  In  60  per  cent,  of  pregnant 
women  there  is  some  hypertrophy  of  the  gums. 

Gingivitis. — In  this  disease  the  gums  are  spongy,  inflamed, 
bleed  easily,  and  are  possibly  ulcerated.  The  condition  may 
obstinately  resist  treatment  until  pregnancy  is  concluded.  Occa- 
sionally the  gingivitis  extends  to  a  stomatitis,  and  rarely  lasts 
through,  and  is  aggravated  by  lactation,  only  disappearing  when 
the  child  is  weaned.  The  inflammation  may  extend  down  the 
esophagus  to  the  stomach,  producing  dyspepsia  and  an  obstinate 
vomiting.  Astringent  and  cleansing  mouth-washes,  containing 
tincture  of  myrrh,  give  the  best  results  in  the  treatment  of  this 
affection. 

Toothache  may  develop  with  or  without  pathological  changes 
in  the  mouth,  and  in  the  latter  case  may  resist  treatment.  It 
usually  subsides  in  the  second  half  of  gestation  if  it  is  a  neurosis. 
If  it  is  due  to  dental  caries,  temporary  dental  treatment  should 
give  relief. 

Ptyalism  occurs  usually  in  the  first  half  of  pregnancy.  The 
saliva  is  alkaline  and  ptyalin  is  lacking.  The  causes  are  the  same 
as  those  of  pernicious  vomiting.  They  are :  a  neurosis,  a  reflex  irri- 
tation of  the  sympathetic  nervous  system,  or  an  auto-intoxi- 
cation. Astringents,  belladonna,  chloral,  etc.,  may  be  employed. 
It  disappears  usually  in  the  later  months,  but  may  recur  in  each 
succeeding  pregnancy.  One  of  my  patients  had  salivation  in  five 
successive  pregnancies.  Every  night  a  large  receptacle  was  placed 
by  the  bedside  into  which  saliva  was  expectorated  in  astonishing 
quantities.  A  case  is  reported  in  which  1600  c.c.  (51  oz.)  was 
expectorated  daily  (Tevoff). 

The  Stomach. — There  is  a  physiological,  an  exaggerated, 
and  a  pernicious  vomiting  in  pregnancy.  The  last  is  a  serious 
disease,  with  a  high  mortality. 

Pernicious  vomiting  is  such  an  exaggeration  of  the  physio- 
logical nausea  and  vomiting  of  pregnancy  that  the  stomach 
becomes  almost  or  quite  unrctentive. 


238  PREGNANCY. 

Causes. — There  are  three  causes  for  the  pernicious  vomiting 
of  pregnancy :  toxemia,  reflex  irritation,  and  a  neurotic  condition 
of  the  individual.  The  toxemic  vomiting  in  early  pregnancy  is 
not  yet  satisfactorily  explained.  The  most  reasonable  theory  is 
an  intoxication  from  the  cells  of  the  syncytium,  the  balance  between 
hemolysis  and  syncytiolysis  being  disturbed.  The  toxemic  vom- 
iting late  in  pregnancy  depends  upon  an  imperfect  elimination 
or  oxidization  of  the  products  of  fetal  metabolism,  and  is  usually 
associated  with  kidney  insufficiency  and  albuminuria.  The  urine 
should  always  be  carefully  examined  if  vomiting  appears  late  in 
pregnancy.  The  reflex  vomiting  is  due  to  an  irritation  of  the 
stomach  from  the  distention  of  the  uterus  and  an  irritation  of  the 
latter's  sympathetic  nerve-endings,  in  consequence  of  the  stretching 
of  the  uterine  walls.  It  is,  therefore,  more  common  in  primigrav- 
idas,  especially  in  elderly  Women ;  in  twin  pregnancies ;  in  hydram- 
nios;  in  chronic  metritis  or  displacements  of  the  uterus,  especially 
if  complicated  by  adhesions;  in  cases  of  chronically  thickened, 
inelastic,  or  diseased  cervices,  and  in  a  hyperesthetic  or  disordered 
condition  of  the  nervous  system.  In  one  of  my  cases  I  had  re- 
moved five  fibromyomas  by  enucleation  three  months  before 
impregnation.  Another  cause  may  be  found  in  inflammation 
of  the  lining  mucous  membrane  of  the  cervix  or  of  the  uterus. 
Engorgement  or  inflammation  of  neighboring  organs,  as  inflamed 
tubes  or  ovaries,  or  an  old  or  fresh  appendicitis,  increases  the 
irritation  of  the  distending  womb,  usually  by  reason  of  adhesions 
which  bind  it  down.  A  pathological  condition  of  the  stomach, 
as  gastroptosis,  chronic  gastritis,  or  gastric  ulcer,  naturally  increases 
gastric  irritability,  so  that  the  stomach  feels  acutely  the  reflex 
irritation  of  pregnancy.  There  may  rarely  be  some  pathological 
condition  of  the  intestinal  tract,  as  polypi  or  bands  of  adhesions^ 
as  a  cause  of  pernicious  vomiting.  Immoderate  indulgence  in 
sexual  intercourse  is  a  not  infrequent  cause. 

The  neurotic  vomiting  appears  in  women  of  the  neurotic  type 
and  may  be  neither  reflex  nor  toxemic;  but  both  reflex  and 
toxemic  vomiting  are  more  likely  to  appear  in  neurotic  women 
or  are  aggravated  in  such  women. 

Diag7iosis. — The  recognition  of  the  cause  may  be  difficulty 
but  the  diagnosis  of  the  condition  is  easy.  There  is  usually  a 
subnormal  temperature,  but  there  may  be  fever  ;  there  is  great 
emaciation,  pallor,  and  loss  of  strength.  The  lips  are  dried  and 
cracked,  the  tongue  is  brown  and  coated,  and  the  breath  foul. 
There  is  constant  retching,  and  everything  put  into  the  stomach 
is  either  immediately  rejected  or  comes  up  undigested  in  a  short 
time.  Whether  anything  is  ingested  or  not,  mucus  and  bile  are 
vomited  from  time  to  time.      A  gastric  ulcer  is  not  uncommonly 


DISEASES   OF   THE   ALIMENTARY  CANAL.  239 

the  result  of  the  disordered  secretion  of  the  stomach  and  the 
reduced  vitality  of  its  walls.  In  such  cases  the  vomiting-  becomes 
bloody  and  the  patient  may  succumb  to  repeated  gastric  hemor- 
rhages, which  she  can  not  endure  in  her  enfeebled  condition. 
The  most  unfortunate  mistake  in  the  diagnosis  of  the  pernicious 
vomiting  of  pregnancy  is  the  failure  to  recognize  the  existence 
of  gestation  and  the  consequent  belief  that  the  emesis  is  that 
of  hysteria,  gastric  ulcer,  or  cancer.  Persistent  vomiting  in  a 
woman  of  child-bearing  age  should  always  arouse  a  suspicion  of 
pregnancy  and  should  always  indicate  a  vaginal  examination. 

An  attempt  has  been  made  to  make  a  differential  diagnosis 
between  reflex  and  toxemic  vomiting  by  the  percentage  of  ammonia 
nitrogen  in  the  urine,  an  increased  percentage  indicating  toxemia. 
The  author's  investigations  so  far  do  not  support  this  contention. 
There  is  an  increase  of  ammonia  nitrogen  in  the  urine  as  a  con- 
sequence of  any  form  of  vomiting;  a  percentage  of  17  has  been 
found  in  a  typical  reflex  case. 

The  treatment  of  hyperemesis  gravidarum  should  be  directed 
toward  the  cause  if  it  is  ascertainable  or  amenable  to  treatment. 
The  various  remedial  measures  required  in  individual  cases  may 
be  conveniently  studied  under  the  following  heads: 

Hygienic. — This  includes  regulation  of  the  diet,  attention  to 
the  gastro-intestinal  tract,  to  the  woman's  sexual  relations,  and  to 
her  mode  of  life.  The  physician  should  advise  a  light  breakfast 
of  tea  and  toast  or  milk,  taken  in  bed  before  getting  up,  the  patient 
lying  flat  upon  her  back.  Resting  quietly  for  a  half-hour  or  so 
after  the  ingestion  of  light,  simple  food,  the  distressing  nausea 
and  vomiting  usually  felt  on  first  rising  in  the  morning  may  be 
entirely  avoided.  Sexual  intercourse  should  be  forbidden.  Oc- 
casionally there  is  improvement  when  the  sensation  of  swallowing 
is  removed  by  a  cocain  spray  of  the  fauces,  or  by  injecting  food 
into  the  stomach  through  an  esophageal  tube.  Lavage  of  the 
stomach  and  of  the  colon  has  been  beneficial.  An  electrical 
current  applied  over  the  neck  and  the  epigastrium  has  occasion- 
ally been  of  service.  Rectal  alimentation  must  be  resorted  to 
in  the  worst  cases,  the  enemata  being  non-irritating,  so  as  not 
to  provoke  an  exhausting  diarrhea,  partially  digested,  easily 
absorbed,  and  not  administered  in  too  large  amounts  or  too 
frequently.  Four  to  six  ounces  may  be  given  three  or  four 
times  a  day,  of  liquid  peptonoids,  pancreatized  milk,  or  pep- 
tonized beef-tea.  The  rectum  should  be  washed  out  twice  a 
day,  and  after  the  irrigation  a  pint  of  normal  salt  solution 
should  be  injected  high  up  in  the  bowel  for  the  relief  of  the 
distressing  thirst  that  is  a  constant  symptom.  A  tolerance 
of  the   stomach  may  at  times   be  secured   by  allowing   appar- 


240  PREGNANCY. 

ently  unsuitable  articles  of  food  if  they  are  strongly  craved  by 
the  patient.  In  all  cases  of  true  pernicious  vomiting-  the  patient 
must  be  confined  to  bed,  the  room  should  be  darkened  and  kept 
absolutely  quiet,  and  every  atom  of  the  patient's  strength  should 
be  saved  by  careful  nursing. 

It  must  be  remembered  that  the  vomiting  of  pregnancy  is 
sometimes  a  neurosis.  Hence  a  strong  nervous  impression  upon 
the  patient  or  the  establishment  of  a  moral  control  over  her,  as  in 
the  treatment  of  hysteria,  will  often  give  brilliant  results.  A  case 
of  hyperemesis  may  be  cured  by  making  a  vaginal  examination, 
and  the  entrance  into  the  patient's  bedroom  of  a  consultant  may 
immediately  check  a  vomiting  previously  uncontrollable.  Again, 
a  positive  statement  that  a  certain  remedy  would  unfailingly  stop 
the  vomiting  has  made  it  immediately  successful.  In  one  case  the 
appointment  to  induce  abortion  the  following  day  so  frightened 
the  patient  that  she  never  vomited  again. 

The  Medicinal  Treatment. — The  drugs  that  have  been  lauded 
as  specifics  in  the  treatment  of  hyperemesis  include  a  large  pro- 
portion of  those  in  the  pharmacopeia.  The  remedies  most 
worthy  of  mention  are:  lodin,  gtt.  j-ij  (0.06  to  0.12  c.c.)  in 
water;  oxalate  of  cerium,  subnitrate  of  bismuth,  tincture  of  nux 
vomica,  antipyrin,  wine  of  ipecacuanha  in  small  doses,  menthol, 
hydrobromate  of  hyoscin,  and  cocain.  The  nerve  sedatives — 
the  bromids,  chloral,  and  opium — are  the  most  reliable  (sodium 
bromid,  gr.  x  (0.65  gm.),  in  aq.  camph.,  3iv  (15.50  gm.),  four 
times  a  day,  is  a  useful  routine  prescription).  If  the  stomach  is 
intolerant  of  drugs,  recourse  may  be  had  to  enemata  of  sodium  or 
potassium  bromid,  gr.  xl  (2.60  gm.),  and  chloral,  gr.  xx  (1.3  gm.), 
two  or  three  times  a  day,  dissolved  in  several  ounces  of  water. 
Injections  of  normal  salt  solution  in  the  bowel  or  under  the  breast 
have  succeeded  in  some  cases,  it  is  claimed,  by  washing  the  blood, 
stimulating  the  kidneys,  and  thus  combating  a  gestational  toxemia. 
In  the  early  stages  of  the  disease  calomel  and  salts  may  be 
effectual. 

The  Gynecological  Treatment. — If  the  vomiting  of  pregnancy 
becomes  exaggerated  and  resists  the  ordinary  hygienic  and 
medicinal  treatment,  a  vaginal  examination  should  be  insisted 
upon.  Various  abnormal  conditions  of  the  pelvic  organs  may 
be  discovered  and  must  be  treated.  A  displaced  uterus  must  be 
replaced.  If  the  cervix  is  engorged,  thickened,  or  cicatricial,  or 
if  its  canal  is  inflamed,  applications  may  be  made  to  it  through  a 
cylindrical  speculum,  a  twenty-grain  solution  of  nitrate  of  silver, 
for  example,  being  poured  into  the  speculum  until  the  cervix  is 
submerged  in  it.  Multiple  punctures  of  the  cervix  or  the  use  of 
glycerin  tampons  may  be    considered,   though  these    measures 


DISEASES    OF   THE   ALIMENTARY  CANAL.  24I 

would  be  employed  at  the  risk  of  inducing  abortion.  Peroxid 
of  hydrogen  has  been  found  useful  poured  into  the  speculum  as 
just  described.  It  is  obvious  that  if  applications  to  the  cervical 
canal  are  made  with  an  applicator  and  cotton,  abortion  might 
result.  If  there  is  metritis,  with  a  large,  heavy,  inelastic  womb, 
treatment  may  not  accomplish  much  during  pregnancy.  Glyc- 
erin tampons  may  be  tried  if  the  knee-chest  posture,  rest  in  bed, 
and  free  purgation  fail,  but  they  may  induce  abortion.  An  adher- 
ent, displaced  womb,  with  old  or  recent  peri-uterine  inflammation, 
is  not  infrequently  responsible  for  a  particularly  obstinate  and  vio- 
lent form  of  emesis.  Pelvic  massage,  vaginal  packing,  or  the  col- 
peurynter  must  be  resorted  to  at  the  risk  of  terminating  pregnancy. 
An  operation  for  appendicitis  during  pregnancy  may  be  indicated. 
A  strong  solution  of  cocain,  applied  to  the  cervix  and  to  the  vagi- 
nal vault,  has  been  beneficial  in  a  few  cases.  Dilatation  of  the  cer- 
vix with  the  fingers  or  with  a  bougie  has  occasionally  been  won- 
derfully successful.  This  so-called  Copeman  plan  of  treatment 
has  many  enthusiastic  advocates,  but  experience  has  taught  me 
that  it.  is  unreliable.  Its  occasional  success  is  explained,  I  believe, 
by  the  nervous  impression  produced  upon  the  patient. 

The  Obstetrical  Treatment. — Induction  of  abortion  or  of  pre- 
mature labor  should  be  regarded  as  the  last  resort,  but  it 
should  not  be  delayed  too  long.  If  a  patient  retains  absolutely 
nothing  on  her  stomach  and  must  be  fed  by  the  rectum  ;  if  she 
vomits  incessantly  whether  anything  is  put  into  the  stomach  or 
not ;  if  the  pulse  rises  to  1 20  and  the  prostration  is  really  alarm- 
ing, abortion  must  be  induced.  As  a  rule,  I  do  not  continue 
rectal  alimentation  more  than  a  week.  There  is  one  case  on 
record  in  which  rectal  feeding  was  employed  with  success  for 
almost  two  months,  but  this  single  instance  should  not  encourage 
physicians  to  persist  for  an  inordinate  length  of  time  in  rectal 
alimentation.  There  are  many  deaths  recorded  of  women  fairly- 
well  nourished  by  food  injected  in  the  bowel,  but  fatally  ex- 
hausted by  incessant  retching  and  vomiting. 

It  has  been  claimed  that  a  high  percentage  of  ammonia  nitrogen 
in  the  urine  indicating  a  toxemic  vomiting  calls  for  the  induction 
of  abortion.  But  as  this  condition  may  be  an  effect  and  not  a 
cause,  as  it  is  found  in  reflex  as  well  as  toxemic  cases,  as  a  sponta- 
neous recovery  has  been  observed  with  a  percentage  as  high  as 
thirty,  the  physician  can  not  be  guided  by  this  test  in  deciding  for 
or  against  the  radical  treatment. 

The   mortality  of  the  pernicious   vomiting  of  pregnancy  is 

high.      Of  239  cases,  95  died  ;  of  57  cases  treated  by  the  usual 

means,  28  died  ;  of  36  cases  treated  by  the  induction  of  abortion, 

9  died.     I  have  induced  abortion  for  hyperemesis  fifteen  times. 

16 


242  PREGNANCY. 

Two  patients  died.  In  one  case  I  was  called  to  see  the  woman 
in  consultation  when  she  was  almost  moribund.  The  induction 
of  abortion  proved  too  great  a  shock  to  her,  easy  and  simple  as 
the  operation  is.  In  the  other  case  the  religious  scruples  of  the 
family  prevented  the  termination  of  the  pregnancy  when  I  first 
advised  it.  Ten  days  later,  the  patient  being  obviously  at 
death's  door,  the  operation  was  demanded,  but  was  performed 
too  late. 

The  Intestines. — Constipation  should  be  guarded  against  to 
prevent  overwork  of  the  kidneys.  The  small  compressed  pill  of 
aloin,  belladonna,  cascara,  and  str}''chnin,  kept  in  stock  by  all 
pharmacists,  is  a  good  routine  remedy.  My  routine  prescription 
at  present  is: 

R .     Phenolphthalein, 

Ext.  cascar. , 

Ext.  colocynth.  com aa  gr.'j  ; 

Ext.  nuc.  vom., 

Ext.  belladonn aa  gr.  ■^■^. 

Sig. — In  pill  form  at  bed-time. 

The  weaker  mineral  waters,  effervescent  phosphate  of  soda, 
and  pulv.  glycyrrhizae  comp.,  may  be  used.  A  mild  course  of 
calomel  followed  by  a  Seidlitz  powder  is  indicated,  as  a  rule,  about 
once  a  month.  Active  purges  not  only  disturb  digestion,  but  may 
interrupt  gestation.^ 

Diarrhea. — When  the  ordinary  astringent  remedies  fail  to 
check  a  diarrhea  in  pregnancy,  nerve  sedatives  should  be  tried. 
There  is  a  nervous  diarrhea  of  pregnancy  due  to  the  mechanical 
irritation  of  the  intestines  by  the  growing  uterus. 

Gastric  and  Intestinal  Indigestion. — The  latter  is  not  uncommon 
in  primigravidse,  and  may  give  rise  to  such  severe  abdominal  pains 
that  a  suspicion  of  extra-uterine  pregnancy  seems  justified.  These 
conditions,  too,  may  be  a  neurosis,  and  may  yield  to  valerian, 
bromids,  and  similar  remedies  after  the  ordinar}^  treatment  for 
dyspepsia  has  failed  completely. 

The  liver  is  always  under  a  strain  in  pregnancy.  Toxins 
derived  from  the  ovum  or  the  embryo  are  conveyed  by  the  maternal 
blood  to  the  liver  for  oxygenation  or  preparation  for  elimination, 
mainly  by  the  kidneys.  Jaundice  may  result  from  a  mild  catarrhal 
condition  of  the  bile-ducts,  which  may  have  existed  before  preg- 
nancy. This  class  of  cases  is  of  little  chnical  importance.  It 
should  be  remembered,  however,  that  a  serious  condition  may 

'  Herrgott  reports  a  remarkable  case  of  neglected  constipation  in  pregnancy  in 
which  the  urethra  was  obstructed  and  the  bladder  contained  4450  c.c.  of  urine; 
the  posterior  vaginal  wall  was  pressed  firmly  against  the  anterior  and  the  uterus  was 
displaced  upward  and  to  one  side  by  an  enormous  mass  of  feces,  "Ann.  de  Gyn.," 
April,  1899. 


DISEASES.    OF   THE    ALIMENTARY  CANAL.  243 

develop  in  pregnancy  as  the  result  of  excessive  work  thrown  upon 
the  liver — namely,  an  acute  degeneration  of  the  whole  hepatic 
structure.  Localized  degenerations  of  the  liver  are  seen  in  all 
fatal  cases  of  eclampsia,  and  the  toxins  circulating  in  the  blood  in 
that  disease  may  act  upon  the  liver  like  phosphorus,  producing 
acute  yellow  atrophy. 

J.  \Vhitridge  WilHams,  in  his  studies  of  the  liver  in  the  toxemias 
of  pregnancy,  demonstrates  a  most  interesting  difference  between 
the  degeneration  of  the  toxemia  of  early  pregnancy  with  excessive 
vomiting  and  that  of  the  toxemia  of  late  pregnancy  with  kidney  in- 
sufficiency and  eclampsia.  In  the  one  the  atrophic  and  necrotic 
process  begins  in  the  center  of  the  lobule,  extending  to  the  periphery; 
•in  the  other  the  process  is  reversed. 

Treatment. — Ks  the  liver  is  called  upon  for  extra  work  in  preg- 
nancy, care  should  be  exercised  not  to  impose  too  heavy  a  burden 
on  it  by  heavy  food,  immoderate  indulgence  of  a  capricious 
appetite,  alcoholic  drinks,  cold,  or  sluggish  action  of  the  bowels. 
Simple  catarrhal  jaundice  is  treated  by  regulation  of  diet  and  of 
the  bowels,  and  by  the  administration  of  calomel  to  secure  a  free 
discharge  of  bile.  The  graver  form  of  hepatic  degeneration  is 
likely  to  be  rapidly  fatal. 

Appendicitis  in  Pregnancy. — B abler  has  collected  235  cases  of 
appendicitis  complicating  pregnancy,  labor,  and  the  puerperium;^ 
Renvall,  253.^  The  author's  experience  with  the  operative  treat- 
ment of  appendicitis  in  pregnancy  has  taught  him  the  following 
lessons:  (i)  If  the  patient  has  an  attack  of  appendicitis  during 
early  pregnancy,  especially  if  she  has  had  an  attack  before,  opera- 
tion should  be  advised.  It  is  easy  in  the  first  half  of  pregnancy 
and  should  not  endanger  the  continuance  of  gestation.  An  opera- 
tion after  the  fifth  month,  on  the  contrary,  is  much  more  difficult, 
and  if  an  attack  occurs  late  in  gestation,  in  consequence  of  intense 
congestion  and  increased  intra-abdominal  pressure,  it  is  likely 
to  be  very  severe,  with  early  perforation  and  virulent  peritonitis. 
(2)  If  there  is  reason  to  suspect  suppuration,  the  median  incision 
is  required  in  operations  after  the  fourth  month;  the  uterus  should 
be  hfted  out  of  the  abdominal  cavity  to  detect  ]jossible  areas  of 
suppuration  deep  in  Douglas's  pouch  or  on  the  left  side.  If  there 
is  no  suppuration  or  peritonitis,  the  lateral  incision  is  much  better 
and  safer.  (3)  If  it  is  necessary  to  deliver  the  uterus  from  the  ab- 
dominal cavity  after  the  seventh  month,  it  should  be  emptied  by  a 
Cesarean  section  before  it  is  replaced  in  the  abdominal  ca\ity, 
(4)  Diffuse  suppuration  and  the  necessity  for  drainage  is  not  neces- 

1  "Perforative  appendicitis  complicating  pregnancy."  Journ.  Am.  Med.  Assoc, 
Oct.  17,  1908. 

2  "  Mitteilungen  aus  der  Gyn.  Klin,  des  Prof.  D.  Otto  Engstrom,"  Bd.  vii.,  li.  3, 
Berlin,  1908. 


244 


PREGNANCY. 


sarily  incompatible  with  recovery  or  the  continuance  of  pregnancy. 
In  one  of  the  author's  cases  at  four  and  one-half  months,  the  woman 
recovered  and  went  to  term. 

Hemorrhoids. — The  pelvic  congestion  of  pregnancy  and  the 
mechanical  interference  with  the  circulation  by  the  bulk  of  the 
gravid  uterus  predispose  to  hemorrhoids,  and  aggravate  them 
if  they  antedate  conception.  Palliative  treatment  alone  is  per- 
missible. An  ointment  of  equal  parts  of  ung.  gall,  and  ung. 
stramon.  will  be  found  serviceable.  Cocain,  lead  salts,  and 
opium  may  also  be  useful.  Rest  in  the  horizontal  posture,  the 
knee-chest  posture  several  times  a  day,  and  the  routine  use  of 
laxatives  may  be  necessary.  As  in  all  cases  of  hemorrhoids,  the . 
bidet  gives  great  comfort. 

DISEASES  OF  THE  URINARY  APPARATUS. 

Examination  of  the  Urinary  Tract  and  of  the  Urine — 
Cystoscopy  and  Catheterization  of  the  Ureters  is  required  for  many 
complications  and  consequences  of  the  child-bearing  process. 
Two  cystoscopes  are  needed,  one  for  water,  the  other  for  air 
distention  of  the  bladder.  I  find  the  Tilden  Brown  best  for  the 
former,  the  Eisner  cystoscope  best  for  the  latter.     In  using  the 


Brown's  ureter- catheter  cystoscope. 


water  distention  instrument  the  bladder  should  be  irrigated  and 
filled  with  an  oxycyanide  of  mercury  solution  (i :  5000).  For  the  air 
distention,  the  position  indicated  in  Fig.  174  is  necessary.  With 
either  cystoscope  the  catheterization  of  the  ureters  is  easy,  but  the 
air  distention  is  impracticable  late  in  pregnancy.  In  looking  into 
a  pregnant  woman's  bladder,  allowance  must  be  made  for  the  ex- 
treme distention  and  multiplication  of   the  blood-vessels,  which 


DISEASES   OF   THE    URINARY  APPARATUS. 


245 


under  any  other  circumstances  would  be  pathological.  If  it  is 
necessary  to  obtain  the  urine  from  the  two  kidneys  separately  and 
the  urethral  catheters  cannot  be  used,  or  urine  does  not  flow  from 
them  satisfactorily,  the  Luys's  segregator  should  be  used.    For  the 


Fig.  174- — Position  of  patient  for  air  distention  cy.stiisc()])v,  recjuirini;  lony  leg 
supports,  set  further  back  in  the  authors  operating  table  than  in  the  ordinary  Edebohl 
position.      The  body  held  in  position  by  shoulder  clamps. 


Fig-  175- — Urethroscope  and  its  obturator. 

examination  of  the  urethra  the  instrument  sliown  in  Fig.  175  will 
be  found  most  satisfactory. 

The  urinalysis  ordinarily  refiuired  in  tlie  child-lx-aring  woman 
is  described  on  p.  188.     If  more  complicated   or  delicate  inves- 


246 


PREGNANCY. 


Fig.  176. — Eisner's  ureter  cystoscope  :  A,  Catheter;  B.  catheter  carrier  tubes; 
C,  cystoscope  ;  D,  obturator ;  E,  window  ;  F,  dilating  bulbs ;  G,  stop-cock ;  H, 
lamp;  I,  irrigator  and  aspirator;  K,  current  attachment;  AI,  Eisner  stiletto  probe ; 
N,  cocain  applicator. 


Fig.  177. — Luys's  instrument  for  the  intravesical  separation  of  the  two  urines. 

tigations  are  necessary,  the  student  is  referred  to  special  manuals 
on  the  subject. 

Kidneys, — The  Kidney  of  Pregnancy. — There  is  a  pathological 
condition  of  the  kidneys  so  frequently  developed   in   pregnancy 


DISEASES   OF   THE    URINARY  APPARATUS.  247 

(fifty-eight  out  of  seventy,  Fischer  ^)  that  it  deserves  the  name  of 
*' kidney  of  pregnancy." 

Pathology. — There  is  anemia  with  fatty  infiltration  of  the  epi- 
thelial cells,  without  acute  or  chronic  inflammation. 

Etiology. — The  causes  of  the  common  changes  in  the  kidney 
during  pregnancy  are  still  obscure.  They  have  been  attributed 
to  pressure  on  the  renal  blood-vessels,  to  the  direct  compression 
of  the  kidneys  by  the  gravid  uterus,  to  a  serous  condition  of  the 
blood  in  pregnancy,  to  the  influence  of  the  weather,  to  pressure 
upon  the  ureters,  and  to  spasmodic  contraction  of  the  renal  arteries. 
It  is  most  likely  that  the  condition  is  due  to  a  diminution  of 
the  blood-supply,  most  probably  brought  about  by  increased 
intra-abdominal  tension  and  by  a  contraction  of  the  arterioles  in 
the  kidneys,  due  to  the  irritation  to  which  they  are  subjected 
by  the  products  of  metabolism  contained  in  superabundance  in 
the  blood  of  pregnant  women. 

Symptoms. — There  is  often  albuminuria  in  advanced  degrees 
of  the  condition.  Hyahne  and  granular  casts,  with  epithelium 
filled  with  fat,  may  be  found.  The  kidneys  may  prove  physio- 
logically insufficient,  and  there  may  appear  all  the  symptoms  of 
renal  insufficiency  observed  in  true  nephritis. 

Frequency  and  Course. — About  six  per  cent,  of  ail  pregnant 
women  have  albumin  in  the  urine  in  decided  amounts,  though  a 
vastly  larger  proportion  show  some  degree  of  the  kidney  of  preg- 
nancy, if  there  is  an  opportunity  for  a  postmortem  examination. 
Albuminuria  occurs  most  frequently  in  primigravidas.  The  kidney 
disturbance  runs  a  subacute  course,  manifesting  itself  most  plainly 
in  the  latter  months  of  gestation.  It  may  influence  the  general 
health,  the  course  of  pregnancy,  and  the  occurrence  of  eclampsia, 
just  as  inflammatory  renal  diseases  would  do.  The  renal  insuffi- 
ciency exerts  a  malign  influence  upon  the  fetus,  also,  especially  in 
the  production  of  placental  apoplexies.  If  the  mother  becomes 
uremic,  the  fetus  is  also  poisoned  and  rarely  survives  its  birth 
more  than  a  few  hours.  The  dangers  to  both  mother  and  child 
are  greatest  if  the  condition  develops  suddenly.  The  renal  in- 
sufficiency of  the  kidney  of  pregnancy  disappears  with  the 
cessation  of  gestation. 

The  treatment  is  practically  the  same  as  for  true  nephritis, 
so  that  the  management  of  the  kidney  complications  of  pregnancy 
will  be  considered  without  reference  to  the  cause  of  tlie  kidney 
insufficiency. 

Acute  and  Chronic  Nephritis. — These  diseases  may  occur  at 
any  time   during  pregnancy,  with  their  usual   symptoms.      The 

1  "  Prager  med.  Wocliens.,"  1S92,  No.  17. 


248 


PREGNANCY. 


extra  amount  of  work  thrown  upon  the  kidneys  during  pregnancy 
makes  the  prognosis  of  kidney  diseases  graver  than  at  other 
periods  of  adult  life,  and  a  more  energetic  treatment  may  be 
demanded  in  the  pregnant  than  in  the  non-pregnant  woman. 
Premature  expulsion  of  the  ovum  and  outbursts  of  eclampsia  are 
frequent.  Chronic  nephritis  may  be  acquired  before  or  during 
pregnancy.  Acute  nephritis  or  a  sudden  insufficiency  of  the 
kidneys  may  be  the  result  of  exposure  to  cold,  wet  feet,  sitting 
in  a  draft  when  overheated,  or  a  single  gratification  of  a  ravenous 
appetite. 

Differential  Diagnosis  between  True  Nephritis  and  the  Kidney 
of  Pregnancy. — If  the  kidney  disease  existed  before  pregnancy, 
well-marked  symptoms  will  develop  in  the  earlier  months. 
The  appearance  of  the  first  symptoms  after  the  sixth  month 
usually  justifies  the  assumption  that  the  disease  has  had  its 
origin  during  pregnancy,  and  is  nothing  more  than  the  tempo- 
rary disturbance  of  that  condition.  I  have,  however,  seen 
eclampsia  break  out  in  the  last  month  of  pregnancy  or  during 
labor  in  a  woman  who  had  a  history  of  violent  headaches  and. 
scanty  urination  for  two  years  before  conception,  and  in  another 
who  had  had  scarlet  fever  during  girlhood.  In  both  these  women 
there  was  probably  a  latent  nephritis,  though  there  was  not  a 
sign  of  it  in  pregnancy  until  the  onset  of  the  convulsions.  The 
following  differential  signs  may  aid  one  in  the  diagnosis  of  a 
doubtful  case  : 


Chronic  Nephritis. 
The  history  may  point  to  its  existence 
before  pregnancy. 

Quantity  of  urine  increased  and  its  spe- 
cific gravity  low ;  but  these  condi- 
tions are  normal  in  pregnancy. 

Sudden  diminution  in  quantity  may 
appear. 

Occasional  presence  of  albumiimric 
retinitis. 

The  symptoms  of  kidney  insufficiency 
— allDuminuria,  edema,  somnolence, 
headache — apt  to  be  pronounced  in 
the  earlier  months. 

The  autopsy  shows  inflammatory 
changes,  chronic  or  acute. 


Persists  after  deliver}^ 

Casts  appear  early  and  in  abundance. 


Kidney  of  Pregnancy. 

The  history  would  indicate  that  the 
kidneys  were  normal  before  concep- 
tion.   - 

Quantity  of  urine  likely  to  be  increased 
and  its  specific  gravity  is  low. 

Sudden  diminution  possible,  as  in  true 
nephritis. 

Does  not  appear  in  the  kidney  of  preg- 
nancy, so  far  as  my  observation 
goes, 

Do  not- appear,  as  a  rule,  until  after  the 
sixth  month  of  gestation. 

Anemia  and  fatty  degeneration  of  the 
kidney  are  found  postmottem.  No 
inflammatory  changes,  though  the 
kidneys  may  become  secondarily 
congested  if  convulsions  have  oc- 
curred. 

Disappears  after  delivery. 

Casts  only  in  bad  cases,  not  appearing 
usually  until  the  other  symptoms  of 
kidney  insufficiency  have  developed. 


DISEASES   OF   THE    URIXAR  V  APPARA  TUS.  249 

Treatment. — It  is  important  to  know,  in  any  case  of  pregnancy, 
the  condition  of  the  kidneys;  hence  in  all  cases  the  urine  should  be 
repeatedly  examined,  at  least  every  two  weeks  during  the  earlier 
months  and  once  a  week  during  the  last  month.  If  albumin  ap- 
pears, but  if  its  quantity  is  small,  if  the  total  amount  of  urine  in 
twenty-four  hours  is  not  diminished  below  the  normal,  if  there  are 
no  casts,  no  history  of  a  previous  nephritis,  and  no  symptoms  of 
general  systemic  disturbance,  dietetic  and  hygienic  management 
may  be  sufficient,  so  long  as  the  case  is  kept  under  careful  obser- 
vation. j\Ieat  should  be  eaten  but  once  every  other  day.  Large 
drafts  of  water  should  be  systematically  drunk.  The  greatest 
prudence  must  be  exercised  about  adequate  underclothing,  ex- 
posure to  cold  and  wet  feet,  and  a  laxative  should  be  taken  regularly 
if  it  is  required.  If  the  amount  of  urine  voided  is  decidedly  dimin- 
ished, if  casts  are  discovered  and  edema  appears,  the  patient  should 
keep  her  room  or  should  be  put  to  bed;  the  bowels  must  be  kept 
freely  open;  the  diet  should  be  reduced  to  milk  and  Basham's 
mixture,  or  some  other  diuretic  should  be  given.  Three-grain 
doses  of  caffein  and  benzoate  of  sodium  are  satisfactory.  If  an 
exclusive  milk  diet  is  impossible,  milk  soups,  a  small  amount  of 
toast,  the  lighter  vegetables, — squash,  asparagus,  beets,  salad, 
spinach,  etc., — may  be  allowed  in  small  quantities.  If  under  this 
plan  of  treatment  the  symptoms  grow  progressively  worse,  espe- 
cially if  the  blood  pressure  steadily  rises,  the  termination  of  preg- 
nancy is  necessary.  There  is  no  disease  of  pregnancy  with  which 
the  physician  can  so  ill  afford  to  trifle  as  this. 

Obscurity  of  vision  or  actual  blindness,  demonstrating  usually 
the  presence  of  albuminuric  retinitis,  indicates  the  induction  of 
labor  or  of  abortion  without  a  moment's  unnecessary  delay. 
Both  ophthalmologists  and  obstetricians  of  experience  are  agreed 
that  if  the  woman's  vision,  nay,  if  her  life,  is  to  be  saved,  preg- 
nancy must  be  terminated  at  once.  It  should  be  remembered 
that  if  interference  is  long  postponed,  it  may  come  too  late. 
After  the  uterus  is  emptied  eclampsia  may  occur,  if  the  woman's 
system  is  allowed  to  become  thoroughly  saturated  with  the  effete 
products  of  life  activity  in  both  mother  and  fetus,  which  the 
physiologically  insufficient  kidneys  do  not  excrete.  I  am  in  the 
habit  of  depending  mainly  upon  the  quantity  of  albumin  as  a  guide 
to  determining  the  question  of  inducing  labor.  In  every  case  of 
albuminuria  in  pregnancy  I  have  daily  examinations  made  with 
an  Esbach  albuminometcr  or  by  Purdy's  method.  If,  in  spile  of 
confinement  to  bed,  a  milk  diet,  ingestion  of  large  quantities  of 
water,  diuretics,  and  hot  baths  every  other  day,  the  albumin 
steadily  or  suddenly  increases,  I  terminate  pregnancy.  A  sudden 
diminution   in    the   (luanlity   of   urine,    excessive   edema,    intense 


250  PREGNANCY. 

headache,  failing  vision,  and  somnolence  would  also  decide  the 
question  indubitably  in  favor  of  terminating  gestation.  The 
quantity  of  urea  excreted  is  not  a  reliable  guide  as  to  the  degree  of 
toxemia,  the  sufficiency  of  the  kidney  as  excretory  organs,  and 
does  not  suffice  as  an  indication  for  the  termination  of  gestation. 
I  have  seen  women  with  only  o.i  per  cent,  of  urea  and  but  3  or  4 
grams  a  day  in  perfect  health,  safely  delivered  at  term,  and  others 
with  2  or  3  per  cent,  and  over  30  grams  a  day  profoundly  toxemic. 
Cryoscopy  has  also  failed  to  give  information  of  value  as  to 
threatened  toxemia  or  its  degree.  The  only  clinical  test  furnished 
by  urinary  analysis  which  aids  us  at  present  in  anticipating 
toxemia  or  predicting  its  probable  outcome  is  the  quantity  of 
albumin  in  the  urine.  In  more  than  four- fifths  of  all  the  cases 
of  grave  toxemia  an  increasing  albuminuria  precedes  or  accom- 
panies the  systemic  symptoms. 

Renal  tumors  are  rare.  They  are  to  be  diagnosticated  and 
treated  according  to  the  individual  features  of  the  case,  but  it 
must  be  borne  in  mind  that  any  disease  or  abnormality  of  the 
kidney  predisposes  to  insufficiency  of  excretion.  The  anatomi- 
cally perfect  kidney  is  likely,  but  not  certain,  to  be  physiologically 
sufficient.  The  unhealthy  kidney  will  probably,  but  not  certainly, 
be  insufficient.^ 

Dislocation  of  the  Kidney. — The  right  kidney  is  almost  always 
the  one  affected.  The  displacement  of  the  kidney  is  not  infre- 
quently associated  with  displacements  of  the  gravid  uterus. 
Abortion  may  result  if  the  floating  kidney  happens  to  become 
twisted  upon  its  pedicle.  From  the  pressure  to  which  the 
displaced  kidney  is  subjected,  and  in  consequence  of  interference 
with  the  renal  circulation  b}'  torsion  of  the  vessels,  the  kidney  of 
pregnancy  may  develop.  There  sometimes  occurs  acute  hydro- 
nephrosis with  high  fever,  rapid  pulse,  great  abdominal  tender- 
ness, sudden  increase  in  the  size  of  the  kidney,  and  the  periton- 
itic  expression.  Ice  applications  over  the  kidney  relieved  the 
patient  in  the  single  case  under  the  author's  observation.  A  con- 
genital fixation  of  the  kidney  in  the  pelvis  has  been  noted  in  the 
child-bearing  woman.*  It  is  usually  the  left  (fourteen  out  of 
fifteen  cases  (Cragin) ). 

Diseases  of  the  Pelvis  of  the  Kidney. — Pyelitis  has  the  history 
of  all  the  infectious  diseases  in  pregnancy  ;  it  is  aggravated  by  the 

*  For  two  cases  of  hypernephroma  associated  with  the  child-bearing  act  see 
Noble,  "American  Gynecology  "July,  1902;  Boyd,  "Am.  Jour.  Med.  Sci.,"  June, 
1902. 

2  Cragin  has  collected  five  cases  in  addition  to  his  own.  The  author  has  reported 
a  case  not  included  in  Cragin' s  statistics:   "Am.  Jour,  of  Obstet.,"  July,  1S98. 


DISEASES    OF   THE    URINARY  APPARATUS.  25  I 

condition,  and  reacts  unfavorably  upon  it.  It  is  a  disease  of  the 
last  four  months  of  pregnancy.  Premature  expulsion  of  the  fetus 
is  apt  to  occur.  Pyelitis  is  a  comparatively  frec^uent  complication 
of  pregnancy.  The  right  kidney  is  most  often  ai^ected  for  several 
reasons:  The  torsion  of  the  uterus,  its  right  lateral  inclination, 
and  the  position  of  the  presenting  part  in  the  right  oblique  diameter 
of  the  pelvis  subject  the  right  ureter  to  more  pressure  than  the  left; 
the  common  dislocation  of  the  right  kidney  predisposes  to  conges- 
tion and  to  a  kink  in  the  ureter.  The  attack  may  be  ushered  in 
by  a  chill  and  there  is  often  severe  pain  in  the  renal  region.  The 
fever  may  be  high,  but  is  usually  moderate.  The  pyelitis  may 
be  due  to  lowered  resisting  power  of  the  kidney  the  result  of 
pressure  upon  the  ureters,  and  is  usually  the  result  of  a  colon  bacil- 
lus or  a  gonococcus  infection,  but  the  pathogenic  bacteria  may  be 
staphylococci,  streptococci,  or  tubercle  bacilli.  The  infection  usu- 
ally ascends  from  the  bladder,  but  may  come  from  the  blood. 
There  is  pus  in  the  urine,  but  usually  no  cystitis.  In  obscure 
cases  cystoscopy  and  catheterization  of  the  ureters  may  be  required. 

The  treatment  is  rest  in  bed  on  the  side  opposite  the  diseased  kid- 
ney; ample  draughts  of  water;  salol  and  urotropin;  an  antitoxemic 
diet;  an  ice-bag  over  the  upper  outer  segment  of  the  abdomen  and 
distention  of  the  bladder  by  irrigation  to  excite  peristalsis  in  the 
ureters  and  thus  to  drain  the  kidneys.  Nephrostomy  in  unilateral 
cases  may  be  considered.  Even  nephrectomy  may  be  demanded  if 
the  suppuration  involves  the  substance  of  the  kidney,  but  such  cases 
are  very  rare  in  pregnancy.  They  occur  more  frequently  in  the 
puerperium.  The  induction  of  labor  is  indicated  if  there  are  fever, 
large  quantities  of  pus  in  the  urine,  a  high  leukocyte  count,  and  a 
failure  to  respond  to  treatment.  There  is  usually  a  spontaneous 
recovery  after  labor,  showing  the  influence  exerted  by  the  pressure 
of  the  gravid  womb  upon  the  ureters. "^ 

Hydronephrosis. — A  displaced  and  adherent  gravid  uterus  may 
occlude  the  ureters,  with  this  result.  The  condition  requires  the 
reposition  of  the  uterus. 

A  renal  calculus  is  apt  to  induce  abortion.  Renal  colic  in 
pregnancy  is  to  be  treated  in  the  usual  manner,  without  regard  to 
the  patient's  condition.  The  surgical  treatment  is  not  contra- 
indicated. 

Diseases  of  the  Bladder. — Irritability  is  a  functional  disturb- 
ance, and  occurs  in  an  exaggerated  degree  in  hyperestlietic  in- 
dividuals, who  feel  acutely  the  pressure  of  the  gravid  uterus, 
the  pull  upon  the  uterovesical  ligament,  and  the  congestion  of  all 
the  pelvic  viscera.  Some  degree  of  irritability  of  the  bladder  is 
.seen,  as  a  rule,  in  pregnant  women. 

1  Kendirdjy  collected  62  cases  with  2  deaths,  "  Gaz.  des  hop.,''  April,  1904. 


252  PREGNANCY.    ■ 

The  treatment,  if  any  is  required,  may  consist  of  the  reposition 
of  a  displaced  uterus.  If  the  disturbance  is  purely  neurotic, 
nerve  sedatives  are  indicated. 

The  incontinence  of  retention  is  one  of  the  most  distinctive 
symptoms  of  a  backward  displacement  of  the  gravid  uterus. 
There  may  be,  however,  a  neurotic  incontinence  and  a  paretic 
incontinence  in  pregnancy. 

Vesical  hemorrhoids  are  due  to  an  increased  blood-supply  to 
the  part  and  an  interference  with  the  circulation  by  the  pressure 
of  the  pregnant  uterus.  Hematuria  may  be  a  symptom.  If  the 
loss  of  blood  becomes  alarming,  astringents  may  be  injected 
into  the  bladder ;  the  knee-chest  posture  should  be  assumed 
at  frequent  intervals,  and  the  bowels  must  be  kept  freely 
opened. 

Cystitis  is  more  frequent  after  labor  than  in  pregnancy  ;  com- 
plicating pregnancy,  it  may  be  due  to  gonorrhea. 

Vesical  Calculi. — It  is  important  that  vesical  calculi  be  dis- 
covered before  labor.  They  should  be  removed  through  the 
urethra  or  by  vaginal  lithotomy  during  the  last  month  of  preg- 
nancy, so  that  if  labor  is  induced  by  the  operation,  the  child  shall 
not  suffer  by  reason  of  its  prematurity.  It  is  unfortunate  for  the 
woman  if  she  fall  in  labor  with  an  undetected  stone  in  the 
bladder,      A  vesicovaginal  fistula  is  likely  to  be  the  result. 

Anomalies  of  the  Urine  in  Pregnancy. — Polyuria  is  an  ex- 
aggeration of  the  physiological  increase  of  the  urine  in  pregnancy. 
It  sometimes  reaches  an  astonishing  degree.  One  of  my  patients 
passed  220  ounces  of  urine  a  day.  There  is  usually  great  thirst 
and  the  urine  has  a  very  low  specific  gravity,  but  should  contain 
no  albumin  or  sugar.  The  woman's  health  remains  unimpaired, 
and  it  is  unwise  to  attempt  to  diminish  the  excretion^  After 
delivery,  the  polyuria  disappears. 

The  urine  may  be  diminished  in  quantity,  may  be  high  colored, 
and  may  have  a  high  specific  gravity,  as  the  result  of  errors  in 
diet  and  inactivity  of  the  skin  and  bowels.  This  condition 
should  never  be  regarded  with  indifference.  It  shows  an  in- 
creased strain  upon  the  kidneys  that  may  determine  their  break- 
down. Meat  should  be  temporarily  excluded  from  the  diet. 
The  bowels  should  be  kept  open,  and  Avater  must  be  drunk  in 
large  quantities. 

Lipuria,  occasionally  observ^ed  in  the  pregnant  woman,  is  ex- 
plained by  the  unusual  quantity  of  fat  in  all  the  tissues  of  the 
body,  making  its  way  even  into  the  blood-current.  An  oiled 
catheter  may  be  the  source  of  the  fat.  This  abnormality  does 
not  necessarily  affect  the  woman's  general  health. 


DISEASES   OF   THE   BLADDER.  253 

Chyluria  occasionally,  but  very  rareh%  appears.  It  is  of  no 
pathological  import* 

Peptonuria  and  acetonuria  may  develop  in  pregnancy  in  conse- 
quence of  fetal  death  or  without  ascertainable  cause.  The  latter 
condition  is  not  infrequently  associated  with  eclampsia.  The  char- 
acteristic odor  of  the  woman's  breath  may  be  well  marked. 

Hematuria  may  be  the  result  of  vesical  hemorrhoids.  It 
may,  however,  indicate  acute  cystitis,  ulceration,  a  vesical  tumor, 
stone,  acute  nephritis,  or  some  other  disease  of  the  kidneys  pre- 
disposing to  hemorrhage. 

Mellituria  in  the  pregnant  woman  ranks  next  in  clinical  im- 
portance to  albuminuria.  It  has  been  found  by  some  observers 
in  from  sixteen  to  fifty  per  cent,  of  cases,  but  this  is  not  my  ex- 
perience. In  the  routine  examination  of  the  urine  of  all  pregnant 
women  under  my  charge,  I  do  not  find  sugar  by  FehKng's  test 
in  one  per  cent,  of  the  cases. 

There  are  two  distinct  varieties  of  mellituria  in  pregnancy. 
One  is  due  to  absorption  from  the  breasts;  the  sugar  in  the  urine 
is  lactose,  and  not  glucose."  There  are  no  systemic  symptoms  in 
this  variety.  The  other  is  true  diabetes  mellitus,  which  is  said  to 
occur  more  frequently  in  pregnant  than  in  non-pregnant  women,^ 
and  if  it  exists  before  pregnancy  is  aggravated  by  the  latter  condi- 
tion. In  7  out  of  19  cases  the  disease  determined  fetal  death,  and 
in  4  out  of  15  cases  the  mother  died  shortly  after  labor.'*  Stengel's^ 
more  recent  statistics  shovv^  that  diabetes  mellitus  developing  in 
pregnancy  is  not  quite  so  dangerous  as  was  formerly  supposed  if 
the  patient  is  subjected  to  careful  dietetic  and  medicinal  treatment. 
In  27  pregnancies  among  19  women  there  was  a  satisfactory 
recovery  in  17.  There  were  five  deaths  within  a  few  days  of  the 
labor.  Diabetes  mellitus  may  appear  in  pregnancy  with  all  its 
characteristic  symptoms  and  may  disappear  after  labor.  I  have 
one  patient  who  regularly  develops  the  disease  in  every  preg- 
nancy. It  is  not  certain,  however,  to  reappear  in  subsequent 
gestations. 

Albuminuria. — The  more  exact  and  careful  examination  of  urine 
in  recent  years  shows  a  much  larger  proportion  of  pregnant  women 

1  Meinert,  "  Centralbl.  f.  Gyn.,"  No.  16. 

2  In  cases  of  mellituria  a  chemical  or  polariscopic  examination  should  always  be 
made,  if  possible,  to  determine  the  kind  of  sugar  in  the  urine.  Lactosuria  requires 
no  treatment.     True  glycosuria  demands  rigid  dieting. 

'  The  idea  that  diabetes  mellitus  is  more  likely  to  occur  in  pregnant  than  in 
non-pregnant  women  may  have  been  due  to  the  rather  common  appearance  of  lac- 
tosuria. In  157  cases  of  true  diabetes  mellitus  in  women,  reported  by  Griesinger 
and  Frerichs,  only  three  were  in  pregnant  women. 

"•  Matthews  Duncan,  "On  Puerperal  Diabetes,"'  "Obstet.  Tr. ,"  vol.  xxiv, 
p.  256. 

'  "Univ.  of  Penna.  Med.  Bulletin,"  October,  I903. 


254  PREGNANCY.      ' 

with  albumin  in  the  urine  than  was  formerly  acknowledged. 
Volkmar,  Fischer,  Trautenroth,  Saft,  and  Zangenmeister,  in  920 
examinations  found  an  average  percentage  of  22.42,  but  the 
estimate  varied  from  5.41  per  cent.  (Saft)  to  68.33  P^^  cent.  (Volk- 
mar). The  test  employed  was  acetic  acid  and  ferrocyanide  of 
potassium  and  a  mere  trace  of  albumin  was  regarded  as  albumin- 
uria. If  more  than  a  mere  trace  is  demanded  as  proof  of  albumin- 
uria, the  older  statistics  averaging  6  per  cent,  are  more  accurate, 
and  for  the  purposes  of  the  clinician  the  latter  standard  is  alone 
valuable.  A  faint  trace,  without  increase,  is  of  no  moment..  A 
decided  amount  has  the  most  important  significance,  as  the  first 
premonitory  sign  of  threatened  toxemia  in  four-fifths  or  more  of 
the  cases. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  Brain. — The  inflammatory  diseases  of  the  brain  are  acci- 
dental complications  of  pregnancy  and  are  rare  ;  they  exert  no 
special  influence  upon  gestation,  nor  do  they  modify  its  course, 
except  cerebrospinal  meningitis,  which  is  infectious,  and  therefore 
has  the  same  influence  upon  and  is  influenced  in  the  same  way 
by  pregnancy  as  the  other  infectious  fevers.  That  is  to  say,  it  is 
aggravated  by  the  woman's  condition  and  exercises  a  deleteri- 
ous influence  upon  that  condition. 

Congestion  of  the  brain  predisposes  to  apoplexy,  an  accident 
which,  serious  as  it  is,  has  no  influence  upon  the  course  of  preg- 
nancy or  labor  if  the  woman  recovers  from  the  cerebral  hemor- 
rhage. 

The  Spinal  Cord. — Inflammatory  diseases  of  this  structure  are 
also  accidental  complications,  and  are  without  influence  upon 
pregnancy  or  labor. 

Paralyses: — The  woman  may  be  the  subject  of  paraplegia  and 
yet  pregnancy  and  labor  are  entirely  uncomplicated.  The  latter 
process,  indeed,  is  easier  in  such  women.  It  would  appear,  there- 
fore, that  the  spinal  nerves  exercise  an  inhibitor}'  action  upon  the 
uterine  muscle,  the  removal  of  which  facilitates  parturition. 

The  Peripheral  Nerves. — Obstinate  neuralgias  appear  in  preg- 
nancy, which  may  be  Httle  benefited  by  treatment,  and  only 
disappear  after  labor.  It  should  be  remembered  that  localized 
pains  of  a  neuralgic  character  in  the  head,  face,  or  breast  are 
often  indicative  of  toxemia  in  pregnancy.  Multiple  neuritis  may 
have  its  origin  in  gestation,  especially  in  alcoholic  subjects. 

The  Neuroses  of  Pregnancy. — Chorea. — The  milder  grades 
of  the  disease  are  not  uncommon  in  pregnancy.  Buist  ^  collected 
225  cases.  Sixty  per  cent,  of  the  cases  occur  in  primigravidae. 
Heredity,  chlorosis,  rheumatism,  and  the  existence  of  the  disease 

1  "Trans.  Edinb.  Obst.  Soc,"  1894-95. 


D/SEASES   OF  THE  NERVOUS  SYSTEM.  255 

in  the  patient's  childhood  are  predisposing  causes.  Chorea  is 
almost  always  aggravated  by  the  coexistence  of  pregnancy, 
though  in  one  case  recorded  the  chorea  ceased  when  the  woman 
became  pregnant.  ^  In  the  graver  variet}^  of  the  disease  premature 
expulsion  of  the  ovum  is  apt  to  occur,  followed  by  death  of  the 
mother  in  about  one-fourth  of  the  cases.  Buist's  statistics  give 
45  deaths  out  of  225  cases, — 17.6  percent.  Insanity  is  not 
infrequently  associated  with  or  follows  chorea  in  the  child-bear- 
ing woman. 

Treatment. — Fowler's  solution,  iron,  nerve  sedatives,  change 
of  air,  and  nutritious  diet  are  indicated  in  the  milder  cases.  The 
graver  cases  may  actually  require  an  anesthetic  for  the  temporary 
control  of  the  violent  movements  until  the  induction  of  prema- 
ture labor  can  be  effected,  whereupon  there  is  usually  a  spon- 
taneous recovery  unless  the  termination  of  pregnancy  has  been 
delayed  too  long. 

Epilepsy  is  a  rare  complication  of  pregnancy.  As  a  rule, 
epilepsy  does  not  influence  unfavorably  the  course  of  gestation. 
The  convulsions  are  often  absent  during  pregnancy,  but  make 
their  appearance  again  during  and  after  the  puerperium  or  upon 
the  reappearance  of  menstruation  after  the  child  is  weaned. 
This  disease  is  most  likely  to  be  confused  with  eclampsia  (see 
Eclampsia).  Cases  have  been  reported  in  which  the  infant,  after 
birth,  presented  the  symptoms  of  the  maternal  disease  and  died. 

Hysteria  in  its  minor  grades  occurs  frequently  during  preg- 
nancy, but,  as  a  rule,  does  not  exert  an  unfavorable  influence 
upon  the  course  or  duration  of  gestation. 

Tetany  may  have  its  origin  in  pregnancy  and  may  recur  in  sub- 
sequent pregnancies.^  It  is  usually  mild  in  type,  ending  in  recov- 
ery, but  it  may  possibly  end  fatally,  in  consequence  of  interference 
with  respiration,  by  the  firm  contraction  of  the  thoracic  muscles. 
From  recent  experiments  it  appears  that  the  parath3Toids  have 
some  relationship  with  this  disease  and  that  calcium  salts  internally 
or  parathyroid  extract  is  the  best  treatment. 

Uncontrollable  hiccup  and  coughing  are  usually  pure  neuroses, 
and  yield  most  readily,  if  they  yield  at  all,  to  antispasmodic  reme- 
dies, or  to  a  profound  nervous  impression.  The  induction  of 
labor  may  be  necessary. 

1  In  a  patient  in  the  Maternity  Hospital,  a  young  girl  illegitimately  pregnant, 
a  chorea  which  she  had  had  in  childhood  reappeared  within  a  week  of  the  fruitful 
coitus.  I  was  obliged  to  induce  labor  in  the  eighth  month  on  account  of  the  severity 
of  the  symptoms. 

^Neumann,  "  Zwei  Falle  von  Tetanic  Gravidarum,"  "  Archiv  f.  Gyn.,"  Bd. 
xlviii,  H.  3;  Meinert,  ibid.,  Bd.  Iv,  H.  2,  has  collected  21  cases;  also  "  Tetanie 
in  der  Schangerschaft,"'  "  Monatschr.  f.  Geb.  u.  Ciyn.,"  January,  1904;  Schmidlech- 
ner  adds  another  case,  "  Zentralbl.  f.  Gyn.,'  No.  4,  1905,  and  Gross  two  more; 
"Muench.  Med.  Wochenschrift,"  No.  t,],,  1906. 


256  PREGNANCY. 

Organs  of  Special  Sense. — Eyes. — Failing  vision  should 
always  indicate  an  examination  of  the  urine  for  signs  of  advanced 
kidney  disease.  Occasionally,  however,  there  occurs  complete 
temporary  blindness,  associated  only  with  anemia  of  the  eye- 
ground,  due  to  a  reflex  contraction  of  the  retinal  artery. 

Hearing. — Disturbances  of  this  sense  are  rare  and  are  usually 
temporary,  but  they  may  be  permanent.  They  are  often  inex- 
plicable. Some  anomaly  of  the  external  auditory  canal  may  be 
found,  as  a  hematoma,  which  was  the  cause  in  one  reported 
case  of  deafness  in  a  gravid  woman.  In  my  experience  the 
hearing  of  a  deaf  person  has  been  worse  during  pregnancy  than 
at  other  times. 

Psychical  Disturbances.^ — Insanity. — Frequency. — Of  all 
cases  of  insanity  in  women,  about  eight  per  cent,  have  their 
origin  in  the  child-bearing  process.  About  one  in  four  hundred 
women  confined  become  insane. 

Predisposing  Causes. — The  nervous  excitation  of  gestation  in 
women  predisposed  by  hereditary  influence  to  mental  breakdown, 
great  reduction  in  physical  strength,  and  prolonged  mental  strain 
or  worry  should  excite  the  physician's  anxiety  for  his  patient's 
mind. 

Exciting  causes  may  be  exaggerated  anemia,  as  from  prolonged 
lactation  ;  septicemia  ;  albuminuria  ;  profound  emotions,  as  exag- 
gerated fear  of  impending  danger  ;  the  remorse  and  shame  of 
illegitimate  pregnancy  ;  the  grief  of  a  deserted  woman  ;  accidents, 
as  hemorrhage  ;  great  physical  or  mental  exhaustion.  Chorea, 
associated  with  insanity,  results  rather  from  the  same  predis- 
posing or  exciting  causes,  and  should  not  be  considered  in  itself 
as  a  cause  of  the  insanity.  In  my  experience,  insanity  in  the 
child-bearing  woman  has  almost  always  resulted  from  some  pro- 
found emotion.  One  of  my  patients  became  insane  after  the 
death  of  her  child  ;  another,  because  her  husband  deserted  her  ; 
a  third,  some  days  after  her  delivery,  received  a  letter  from  her 
seducer  casting  her  off  She  fainted  on  reading  it,  became  a 
raving  lunatic  that  same  night,  and  died  of  maniacal  exhaustion 
within  two  weeks.  Several  cases  were  the  result  of  futile  efforts 
at  delivery  by  operative  procedures  and  repeated  anesthetizations. 
A  number  of  women  under  my  observation  have  lost  their  minds 
from  the  shame  of  illegitimate  impregnation. 

Symptoms. — The  form  of  insanity  may  be  mania,  melancholia, 
or  a  condition  of  profound  lethargy,  stupidity,  and  mental  con- 
fusion. If  a  woman  in  this  last  condition  is  asked  a  question 
in  a  sharp  tone  of  voice,  there  is  a  momentary  flicker  of  intelli- 
gence in  her  face,  but  before  the  import  of  the  question  reaches 


DISEASES  OF  THE  CIRCULATORY  APPARATUS.  257 

her  brain,  she  is  sunk  again  in  her  extraordinary  apathy  and 
indifference  to  her  surroundings. 

Time  of  Ocairrciicc. — Most  frequently  mental  breakdown 
occurs  during  the  puerperium,  next  in  frequency  during  lactation, 
and  least  frequently  during  pregnancy.  Mania  is  the  most,  mental 
apathy  or  confusion  the  least,  frequent  form  of  puerperal  insanity. 
Melancholia  is  commoner  in  pregnancy  than  in  the  puerperium. 

TJie  diagnosis  of  insanity  is  usually  easy.  It  is,  however, 
important  to  distinguish  puerperal  insanity  from  the  temporary 
delirium  of  labor,  delirium  tremens,  the  delirium  of  fever, 
especially  that  of  septicemia,  and  from  preexisting  insanity. 

The  temporary  delirium  of  labor  is  common.  It  is  usually 
momentary,  in  the  midst  of  the  most  acute  suffering  of  labor, 
and  varies  in  degree,  from  an  outbreak  of  hilarity  to  violent 
mania. 

Delirium  Tremens. — Labor,  like  an  accident  or  surgical  ope- 
ration, may  precipitate  an  attack  in  hard  drinkers.  The  history 
of  the  patient,  and  her  symptoms,  should  demonstrate  the  nature 
of  the  case. 

The  delirium  of  fever  in  child-bearing  women  is  commonly 
due  to  septic  infection.  It  is  frequently  necessary  to  wait  until 
the  fever  subsides  to  determine  if  it  be  the  cause  of  the  mental 
symptoms. 

Preexisting  insanity  is  recognized  by  the  previous  history  of 
the  patient,  if  it  can  be  obtained. 

Prognosis. — About  two-thirds  of  the  women  recover  their 
reason  in  from  three  to  six  months  ;  of  the  other  third,  from  two 
to  ten  per  cent,  die  of  septic  infection  or  exhaustion  ;  the  rest 
remain  permanently  insane. 

The  treatment  is  best  carried  out  in  an  asylum.  Many  patients, 
hov/ever,  will  not  be  allowed  by  their  families  to  enter  an 
asylum.  In  such  cases  a  modified  rest-cure,  combined  with 
administration  of  iron,  arsenic,  and  a  nutritious  diet,  together 
with  systematic  exercise  in  the  open  air,  will  hasten  the  cure. 
The  most  careful  supervision  must  be  exercised  at  all  times,  to 
prevent  the  patient  doing  an  injury  to  herself,  her  infant,  or  her 
attendants. 

DISEASES  OF  THE  CIRCULATORY  APPARATUS. 

Under  this  heading  are  considered  those  diseases  of  the  heart, 
of  the  thyroid  gland,  of  the  blood-vessels,  and  of  the  blood, 
which  have  their  origin  in  pregnancy  or  are  much  aggravated 
by  that  condition. 

The  Heart. — Valvular  disease  of  the  heart  usually  antedates 
17 


258  PREGNANCY.     - 

impregnation.  It  may,  however,  owe  its  origin  to  septic  infection 
during  the  child-bearing  process,  or  to  rheumatism  acquired 
after  conception.  A  woman  may  have  vahmlar  disease  of  the 
heart  without  murmur  or  other  clinical  signs  until  she  becomes 
pregnant,  when  the  disturbance  of  the  circulation  occasions  a 
loud  heart-murmur  and  symptoms  perhaps  of  heart-weakness. 
One  of  my  patients  has  a  heart-murmur  in  her  pregnancies, 
which  may  be  heard  some  distance  from  her  body,  but  which  is 
inaudible  at  other  times. 

Prognosis. — Abortion  is  induced  in  about  twenty-five  per 
cent,  of  all  cases,  as  the  result  of  placental  apoplexies,  or  of  the 
stimulation  of  the  uterus  to  contraction  by  the  accumulation  of 
carbon  dioxid  gas  in  the  blood.  Pregnancy  distinctly  increases 
the  danger  of  the  heart-lesion.  In  fifty-eight  serious  cases, 
twenty-three  died  after  a  premature,  delivery  of  the  child.  In 
milder  cases  the  prognosis  is  not  grave,  yet  the  woman's  con- 
dition is  by  no  means,  free  from  danger.  The  complications 
particularly  to  be  dreaded  during  gestation  are  :  afresh  outbreak 
of  endocarditis,  fatty  degeneration  of  the  papillary  muscles,  and, 
especially,  congestion  of  the  lungs.  If  the  disease  be  of  long 
standing  and  serious  in  character,  it  appears,  from  statistical 
studies,  that  about  half  the  women  die.^  If  there  is  good  com- 
pensation, however,  there  may  not  be  an  untoward  symptom, 
or,  at  most,  occasional  palpitations,  some  dyspnea,  edema,  and  a 
tendency  to  renal  congestion,  with  albuminuria. 

Treatment. — The  pregnant  woman  with  valvular  disease  of  the 
heart  must  be  carefully  watched.  Her  urine  should  be  examined 
at  frequent  intervals.  On  the  first  appearance  of  symptoms 
pointing  to  inadequate  compensation,  digitalis  or  strophanthus 
must  be  administered,  and  it  is  commonly  necessary  to  increase 
the  dose  as  pregnancy  advances.  The  bowels  must  be  kept 
freely  opened.  Moderate  exercise  in  the  open  air  is  an  advan- 
tage, but  rest  in  the  recumbent  posture  must  be  ordered  at  fre- 
quent intervals  during  the  day.  Meat  should  be  eaten  sparingly 
on  account  of  the  likelihood  of  kidney  breakdown,  and  extra  pre- 
cautions must  be  taken  against  suddenly  throwing  greater  work 
upon  the  kidneys  by  chilling  the  skin.  Flatulent  dyspepsia  is 
not  infrequent  in  cardiac  weakness.  It  should  be  carefully 
treated.  It  is  almost  unnecessary  to  state  that  the  woman  must 
avoid  any  sudden,  violent  physical  effort,  and  should  be  spared 
any  cause  for  mental  excitement.  Finally,  pregnancy  should 
never  be  allowed  to  continue  longer  than  the  thirty-sixth  week 
in  a  woman  who  exhibits  any  symptom  of  imperfect  compensation. 

'  This  is  not,  however,  my  experience ;  with  proper  treatment  I  have  no  fear  of 
heart  disease  in  pregnancy  (see  Dystocia). 


DISEASES  OF  THE  CIRCULATOR  Y  APPARATUS.  259 

The  Heart=muscle. — Suppurative  myocarditis  is  only  seen 
in  connection  with  septic  infection.  Brown  atrophy  of  the  myo- 
cardium has  been  noted  as  a  very  rare  complication  of  preg- 
nancy ;  fatty  degeneration  of  the  heart-muscle  may  occur  acutely 
in  consequence  of  general  systemic  septic  infection,  or  as  a  result 
of  a  gestational  toxemia. 

Graves'  Disease  and  Goiter. — These  diseases  are  unfavor- 
ably influenced  by  pregnancy.  The  former  may  have  its  origin 
in  gestation.  It  predisposes  the  woman  to  uterine  hemorrhages 
and  may  be  a  cause  of  fetal  death.  It  may  and  usually  will  dis- 
appear after  delivery.  I  have  one  patient  in  whom  exophthal- 
mic goiter  with  all  its  classical  symptoms  has  recurred  regularly 
in  three  successive  pregnancies,  the  woman  at  other  times  being 
quite  free  from  the  disease.  A  goiter  may  take  on  so  exag- 
gerated a  development  during  pregnancy  that  asphyxia  is 
threatened,  and  tracheotomy  may  be  necessary.  In  Miiller's 
cHnic  in  Bern  it  was  found  easier  and  better  in  two  cases  to  resort 
to  strumectomy.  The  dislocation  of  the  thyroid  from  behind  the 
sternum  was  immediately  followed  by  relief  of  the  asphyxia.^  In 
a  case  of  Graves'  disease  seen  with  Dr.  Pittfield  a  very  sudden  en- 
largement of  the  thyroid  was  accompanied  by  remarkable  slowing 
of  the  pulse  instead  of  the  tachycardia  which  had  been  marked 
for  some  years.  There  was  probably  pressure  on  the  vagus. 
Graves'  disease  is  likely  to  be  complicated  by  albuminuria.  The 
induction  of  labor  must  be  considered,  but  is  not  usually  necessary. 

The  Blood=vessels. — The  disease  of  most  clinical  interest  in 
these  structures  is  varicose  veins  in  the  rectum,  anus,  broad 
ligament,  bladder,  vagina,  external  genitalia,  the  abdominal  walls, 
and  lower  extremities.  In  the  last  there  may  develop  a  pressure 
edema,  associated  usually  with  varicose  veins. 

The  causes  of  varices  in  pregnancy  are  changes  in  the  invest- 
ing muscular  sheath  of  the  veins,  the  increased  quantit}'  of 
blood,  and  mechanical  obstruction  to  the  circulation  by  the 
bulk  of  the  growing  uterus.  Atheroma  and  degenerative  changes 
may  be  found  in  the  vessel-walls  as  the  result  of  toxemia. 

Complications. — There  may  be  rupture,  with  possibly  a  fatal 
hemorrhage,^  a  severe  interstitial  bleeding,  or  extensive  extravasa- 
tion of  blood  under  the  skin.  Thromboses  and  phlebitis,  with 
suppuration  and  septic  infection,  may  occur.  As  the  result  of 
itching  and  scratching,  eczema  or  even  erysipelas  of  the  affected 
part  may  develop. 

Treatment. — An  elastic  bandage  or  stocking  should  be 
ordered  for  varices  of  the  legs.     Small  doses  of  heart-tonics  are 

i"Centralbl.  f.  Gyn.,"  No.  42,  1903. 

^  In  18  cases  there  were  1 1  deaths  ;  Brunei,  "  Zentralblatt  fi'ir  Clyn.,"  No.  2,  1906. 


26o 


PREGNANCY. 


often  of  service.  Constipation  must  be  avoided.  The  patient 
should  be  advised  to  he  down  at  intervals  during  the  day.  Abso- 
lute rest  must  be  ordered  in  cases  of  thromboses,  to  prevent  em- 
bolism. Lead-water  and  laudanum  should  be  applied  if  there 
is  inflammation.  Abscesses  along  the  course  of  a  diseased 
vein  should  be  opened  early.  A  mechanical  protection  (soap- 
plaster)  should  be  applied  to  the  affected  part  to  prevent  the 
development  of  eczema  or  of  erysipelas.     Itching  may  be  relieved 


Fig.  178. — Varicose  veins  of  the  lower  extremity  in  a  pregnant  woman  at  term. 


by  weak  solutions  of  carbolic  acid  or  by  cocain.  The  woman 
herself  should  be  instructed  how  to  check  hemorrhages,  in  case 
the  distended  veins  burst. 

Aneurysms  are  naturally  unfavorably  affected  by  pregnancy. 
The  hypertrophy  of  the  heart,  the  increased  quantity  of  blood,  and 
the  mechanical  interference  with  the  circulation  in  gestation  are  all 
unfavorable  factors.  Such  a  case  should  be  managed  on  the 
same  principles  that  govern  the  treatment  of  cardiac   complica- 


DISEASES   OF   THE   RESPIRATORY  APPARATUS.  26 1 

tions.       By  this    plan    I    have    successfully  delivered    a  young 
woman  with  an  enormous  aneurysm  of  the  arch  of  the  aorta. 

The  Blood. — Pregnancy  may  have  a  decided  influence  in 
producing  those  blood  diseases  which  are  characterized  by  a 
marked  alteration  in  its  constituent  parts.  Pernicious  anemia  and 
leukemia^  may  have  their  origin  in  gestation,  and  should  they 
already  exist,  they  are  aggravated  by  the  existence  of  pregnancy. 
Pregnancy  should  be  promptly  interrupted  if  these  blood  diseases 
are  obviously  progressing  from  bad  to  worse.  The  anemia  of 
pregnancy  may  be  so  exaggerated  as  to  appear  pernicious,  but 
arsenic,  iron,  and  nutritious  diet  after  delivery  usually  effect 
a  cure.  Purpura  luBviorrJiagica  is  apt  to  be  rapidly  fatal  in  preg- 
nancy, which  it  always  interrupts.  The  disease  usually  destroys 
the  fetus  before  it  is  expelled.  The  maternal  death  may  be  due 
to  postpartum  hemorrhage  or  to  sepsis. 


DISEASES  OF  THE  RESPIRATORY  APPARATUS. 

The  Nose. — The  sense  of  smell  may  be  more  acute,  and 
peculiarities  in  this  sense  are  developed,  as  abhorrence  for  certain 
odors,  which  may  excite  nausea  and  vomiting  in  neurotic  indi- 
viduals. 

More  important  is  the  disposition  to  epistaxis,  which  may  be 
so  severe  as  to  threaten  life.  Epistaxis,  however,  is  a  more 
serious  complication  of  parturition  than  of  pregnancy.  It  can 
only  be  checked  by  the  rapid  termination  of  labor.  Meanwhile 
the  nares  should  be  packed. 

The  Larynx. — If  a  tumor,  tubercular  or  syphilitic  disease  be 
present,  there  is  a  constant  danger  of  edema  of  the  glottis,  which 
requires  tracheotomy. 

The  Bronchi  and  Lungs. — Bronchial  catarrh  ordinarily  is  not 
harmful,  but  prolonged  coughing  may  cause  abortion,  and  the 
hydremic  condition  of  the  blood  in  pregnancy  predisposes  to 
pulmonary  edema.  The  cough  may  have  a  neurotic  element  in 
it,  and  may  be  most  persistent.  In  its  treatment  I  have  obtained 
better  results  from  oil  of  sandalwood  than  from  any  other  single 
remedy. 

Pneumonia. — The  symptoms  of  this  disease  are  much  aggra- 
vated by  gestation,  the  mortality  is  increased,  and  in  the  vast 
majority  of  cases  the  fetus  is  prematurely  expelled  (see 
Pathology  of  Puerperium). 

Emphysema  is  quite  common.      The  symptoms  in  a  pregnant 

^  Schroeder  has  collected  ten  cases  and  reports  one,  "Arch.  f.  Gyn,,"  Bd. 
Ivii,  H.  I,  p.  26. 


262  PREGNANCY.     ' 

woman  are  aggravated,  and  abortion  is  apt  to  occur.  .  In  ad- 
dition to  the  usual  treatment  inhalations  of  oxygen  may  be 
given  to  counteract  the  accumulation  of  carbon  dioxid  in  the 
blood,  which  stimulates  the  uterine  muscle  to  contract,  and  thus 
is  the  chief  factor  in  determining  an  interruption  of  pregnancy. 

Asthma  in  some  women  may  only  appear  during  pregnancy. 
In  such  cases  the  disease  disappears  the  moment  gestation  is 
terminated.  In  other  cases  asthma  may  only  appear  in  labor. 
In  asthmatic  subjects  the  attacks  may  be  much  aggravated  by 
gestation  and  may  obstinately  resist  all  treatment.  Radical 
change  of  air  and  scene  has  proved  efficacious  when  all  medicinal 
remedies  have  failed. 

Phthisis  Pulmonalis. — The  influence  of  pregnancy  upon  this 
disease  is  most  unfavorable,  and  in  women  predisposed  to  tuber- 
culosis gestation  may  be  the  determining  factor  in  lighting  up  an 
attack.  There  is  a  superstition  prevalent  among  the  laity  that 
pregnancy  is  beneficial  to  a  phthisical  patient.  This  idea  has  its 
origin  in  the  accumulation  of  fat  commonly  seen  in  the  pregnant 
woman,  which  gives  her  a  fictitious  appearance  of  improved 
health.  In  reality  the  strain  and  drain  of  child-bearing  exhausts 
the  vitality  of  the  tuberculous  subject  so  seriously  that  her  death 
is  hastened  by  many  months,  and  a  pulmonary  phthisis  that 
might  have  been  arrested  becomes  incurable.  It  is  the  duty  of 
a  physician  to  advise  strongly  against  marriage  and  maternity  in 
the  case  of  a  woman  already  infected  with  or  predisposed  to 
tuberculosis.  If  the  patient  is  pregnant,  the  induction  of  labor 
should  be  considered,  in  some  cases  to  secure  the  birth  of  a  living 
child  before  the  mother's  death,  in  others  to  spare  her  the  drain  of 
the  last  four  weeks  of  pregnancy  and  to  insure  her  an  easy  labor. 
A  tuberculous  woman  should  not  nurse  her  infant. 

Miliary  tuberculosis  is  rapidly  fatal  in  pregnancy  or  shortly 
after  delivery.  It  may  be  mistaken  for  septic  infection.  I  have 
seen  several  cases  in  child-bearing  women  in  which  this  mistake 
was  made.      The  diagnosis  is  extremely  difficult  to  make. 

Pulmonary    embolism    is    a    possible   accident  in    pregnancy. 

Pleurisy  exerts  no  deleterious  influence  upon,  nor  is  it  af- 
fected by,  gestation. 

Hemoptysis  may  occur  in  the  latter  months  of  pregnancy 
without  phthisis  or  other  lung  disease.  It  is  in  these  cases  the 
result  of  "  cardiac  nerve-storms  "  in  pregnant  women  of  neurotic 
character.  The  cheeks  are  suffused,  the  eyes  are  bright,  and  the 
heart  beats  powerfully  and  tumultuously.  The  woman  looks  as 
though  she  had  a  high  fever,  but  her  temperature  is  normal. 
Chloral  and  the  bromids  will  control  the  attack. 


INFECTIOUS  DISEASES.  263 

Diseases  of  the  Osseous  System. — Osteomalacia  of  pregnancy 

is  a  decalcification  of  the  bones  due  to  a  peculiar  osteitis  and 
periosteitis,  the  result  of  malnutrition/  Pott's  disease,  in  its  active 
stage,  is  aggravated  by  pregnancy,  and  the  mortality  is  much 
increased. 

The  infectious  diseases  are  always  more  serious  when  com- 
plicating pregnancy,  their  symptoms  being  more  severe  and  their 
mortality  greater.  Even  measles  at  this  time  may  become  a 
deadly  disease. 

Upon  pregnancy  their  influence  is,  as  a  rule,  unfavorable. 
Sixty-five  per  cent,  of  typhoid=fever  cases  are  complicated  by 
abortion  or  premature  labor.  The  development  of  the  infant 
may  be  seriously  affected  in  prolonged  infectious  fevers  during 
gestation.  Idiocy  has  been  noted  in  a  considerable  number  of 
cases. 

Influenza  is  more  serious  in  pregnancy  than  at  other  times. 
In  6  out  of  21  severe  cases  abortion  and  premature  labor  oc- 
curred.^ 

Auto=intoxication  or  toxemia  in  pregnancy  is  still  the  subject 
of  earnest  study  which  has  thrown  much  additional  light  on  it, 
but  has  not  yet  enabled  any  one  to  speak  dogmatically.  There 
is  an  auto-intoxication  in  the  first  half  of  pregnancy,  probably  due 
to  the  growth  and  secretion  of  syncytial  cells,^  which  produces  a 
hemolytic  agent  and  excites  the  production  of  an  antibody,  syn- 
cytiolysin.  The  chief  symptom  of  the  auto-intoxication  of  early 
pregnancy  is  exaggerated  vomiting.  The  blood-pressure  is  low. 
In  fatal  cases  a  degeneration  of  the  hepatic  lobules  is  found  begin- 
ning in  the  center  and  extending  to  the  periphery  (Williams). 
There  is  also  an  auto-intoxication  in  the  second  half  of  pregnancy, 
probably  due  to  the  reception  into  the  maternal  blood  of  the  prod- 
ucts of  metabohsm  in  the  fetal  body.  The  liver  receives  these 
products  and  breaks  them  up  by  oxidization  into  substances  suitable 
for  elimination,  mainly  by  the  kidneys.  Either  one  of  these  organs 
may  prove  insufficient  for  the  extra  work  thrown  upon  them,  and 
thus  toxins  accumulate  in  the  blood.  As  far  as  clinical  observation 
goes,  the  kidneys  are  more  frequently  at  fault  than  the  liver.  In 
less  than  a  fifth  of  the  cases  toxemia  manifests  itself  without 
precedent  albuminuria.  In  more  than  four-fifths  of  the  cases 
the  symptoms  of  toxemia  are  preceded  by  well-marked  albuminuria 
and  other  symptoms  of  kidney  insufficiency.     The  systemic  symj)- 

1  See  Deformities  of  tlie  Pelvis. 

^  Moller,  "  Deutsch.  med.  Wochenschr.,"  No.  29,  1900. 

■*  Behm,  "Arch.  f.  Gyn.,"  Bd.  Ixix,  H.  2. 


264  PREGNANCY.     ' 

toms  of  the  toxemia  of  late  pregnancy  are  high  blood-pressure,  a 
furred  tongue,  indigestion,  vomiting,  headache,  pain  in  the  epi- 
gastrium. There  are  usually  scanty  urine,  edema,  and  albu- 
minuria. The  chief  symptom  may  be  a  rapid  pulse.  Ultimately 
there  is  somnolence,  failing  vision,  and  finally  an  outbreak  of 
eclampsia.  Of  all  these  symptoms  high  blood-pressure  is  the 
most  constant.  Auto-intoxication  occasions  sometimes  a  train  of 
symptoms  strongly  suggesting  miliary  tuberculosis.  There  is 
irregular  and  prolonged  fever,  profound  emaciation,  and  a  rapid 
pulse.  The  patient  may  appear  hopelessly  ill  and  yet  a  termi- 
nation of  her  pregnancy  immediately  cures  her.  In  a  typical  case 
under  my  observation  the  symptoms  had  continued  six  weeks;  the 
emaciation  was  extreme,  and  the  patient  was  reduced  in  strength 
to  the  last  degree.  An  accomplished  clinician  had  made  the 
diagnosis  of  miliary  tuberculosis.  The  vrom-an  was  in  the  last" 
month  of  pregnancy.  To  save  the  child,  I  induced  labor.  To 
our  astonishment  the  woman  immediately  improved,  and  was 
soon  perfectly  well. 

The  treatment  of  auto-intoxication  has  been  considered  under 
the  head  of  the  kidney  diseases  in  pregnancy  and  of  pernicious 
vomiting. 

Syphilis. — Should  infection  occur  at  the  time  of  impregnation, 
the  primary  sore  and  mucous  patches  in  the  vagina  may  assume 
an  almost  malignant  character,  ulcerating  the  vaginal  mucous 
membrane,  resisting  treatment,  and  seriously  compHcating  the 
puerperal  state.  Flat  condylomata  on  the  buttocks  and  in  the 
natal  folds  are  usually  more  extensive  and  numerous  in  pregnant 
women. 

The  treatment  of  all  the  infectious  diseases  in  gestation  is  to 
be  conducted  with  little  reference  to  pregnancy.  If  abortion  is 
threatened,  the  tendency  should  not  be  combated,  as  the  termina- 
tion of  pregnancy  is  often  of  advantage  to  the  mother,  and  at 
any  rate  can  not  be  averted.  The  treatment  of  syphilis  in  the 
pregnant  woman  is  dealt  with  in  a  preceding  section. 

Skin  Diseases. — The  following  skin  diseases  are  said  to  have 
their  origin  in  pregnancy  : 

Impetigo  Herpetiformis. — The  favorite  seat  of  the  eruption  is 
in  the  groin,  around  the  umbilicus,  on  tlie  breasts,  in  the  axilla. 
The  small  pustules  become  crusts,  around  which  new  pustules 
develop  until  the  entire  surface  of  the  skin  is  covered  in  the 
course  of  three  or  four  months.  Rigors,  high  intermittent  fever, 
great  prostration,  delirium,  and  vomiting  accompany  the  erup- 
tion. 


SA'AV  DISEASES.  26$ 

The  disease  appears,  as  a  rule,  during  the  second  half  of  ges- 
tation. Recent  observation  has  shown  that  it  is  not  absolutely 
confined  to  pregnancy.  Of  twelve  cases  ten  terminated  fatally, 
but  the  disease  did  not  terminate  gestation  prior  to  the  maternal 
death. 

Herpes  gestationis  is  characterized  by  pemiphigoid  efflores- 
cence, exhibiting  erythema,  vesicles,  bullae,  and  scabs.  It  appears 
early  in  pregnancy,  continues  during  gestation,  and  disappears 


0^ 


Fig.  179. — Herpes  yebtaiionis  of  legs,  appearing  as  soon  as  the  ^'oman  realized 
that  she  -was  illegitimately  pregnant ;  first  following  the  course  of  the  nerves  of  the 
leg,  but  later  coalescing. 

during  the  puerperal  state.     Neurotic  symptoms  are  associated 
with  it,  showing  its  probable  nervous  origin. 

Pruritus. — Its  usual  seat  is  the  external  genitalia, — pj'iiritus 
vtilvce.  It  may,  however,  in  rare  cases  be  general.  Caiises  : 
The  disease  is  often  a  neurosis,  but  it  may  depend  upon  irritat- 
ing discharges,  parasites,  or  glycosuria.  Trcatmoit :  Rarely 
in  general  pruritus  it  may  be  necessary  to  induce  premature 
labor,  and  in  pruritus  vulvae  the  irritation  is  sometimes  so  great 
that  the  woman  walks  the  floor  the  greater  part  of  the  night, 
tearing  at  the  vulva  with  the  linger-nails  until  the  llesh  is  raw. 
The  patient  is  brought  to  the  verge  of  insanity  in  this  affection, 
and  the  termination  of  pregnancy  must  be  considered,  but  is  not 
usually  necessary.  A  common  cause  of  pruritus  vulvae  in  preg- 
nancy is  an  irritating  vaginal  discharge,  and  the  most  successful 


266  PREGNANCY.  ' 

treatment  is  a  thorough  disinfection  of  the  vaginal  mucous  mem- 
brane by  pouring  into  a  cylindrical  speculum  a  twenty-grain-to- 
the-ounce  solution  of  nitrate  of  silver,  then  slowly  withdrawing 
the  speculum  so  that  all  the  folds  of  the  membrane  are  successively 
bathed  in  the  solution.  The  treatment  should  be  concluded  by 
a  douche  of  salt  solution  to  neutralize  the  silver  nitrate.  In  cases 
of  purely  neurotic  pruritus  nerve  sedatives  and  a  moral  control 
of  the  patient,  with  a  management  on  the  lines  of  a  rest-cure,  are 
most  effective.  In  the  pruritus  of  glycosuria  dietetic  management 
is  required.  A  boric-acid  ointment  on  the  skin  protects  it  until 
the  sugar  in  the  urine  is  reduced  in  quantity. 

There  are  three  domestic  remedies  that  enjoy  a  consider- 
able reputation  :  very  hot  fomentations,  vinegar,  and  infusion  of 
tobacco.  The  last  must  be  used  sparingly  and  cautiously.  The 
best  medicinal  applications  are  cocain,  menthol,  and  carbolic- 
acid  preparations. 

The  pruritus  dependent  upon  seat-worms  is  treated  by  rectal 
injections  of  infusion  of  quassia. 

Exaggerated  Pigmentation. — Spots  of  quite  dark  pigmentation 
may  appear  on  the  breasts,  thighs,  and  abdomen,  as  large  as  ten- 
cent  pieces  or  a  quarter  of  a  dollar.  The  chloasmata  on  the  face 
may  be  so  exaggerated  as  to  disfigure  the  countenance.  This 
skin  affection  disappears  after  deliveiy,  and  is  not  amenable  to 
treatment  during  pregnancy. 

Loosening  of  the  finger  nails  is  a  painful  affection  of  pregnancy, 
apparently  dependent  upon  malnutrition,  and  usually  appearing 
in  neurotic  individuals.  Nerve  tonics,  especially  strychin,  good 
hygiene,  and  a  general  tonic  treatment  do  something  to  arrest  the 
progress  of  the  disease ;  but  in  the  few  cases  under  my  observa- 
tion (one  recurring  in  three  successive  pregnancies)  the  treatment 
was  only  palliative  as  long  as  pregnancy  continued. 

Injuries  and  Accidents. — Severe  injuries  to  a  pregnant 
woman  usually  result  in  abortion.  Among  the  most  serious 
accidents  of  pregnancy  are  rupture  of  varicose  veitis  in  the  ex- 
ternal genitalia,  the  vagina,  or  lower  extremities.  One  of  the 
rarest  accidents  of  pregnancy  is  rupture  of  the  uterus.  It  may 
occur  spontaneously  in  conseqence  of  a  previous  Cesarean  sec- 
tion, a  myomectomy,  or  a  healed  rupture  of  the  uterus  at  a  former 
labor,  the  scar  bursting  open ;  it  may  be  the  result  of  chronic 
inflammation  and  degeneration  of  the  uterine  walls,  reducing 
them  to  little  more  than  connective  tissue  ;  or  it  may  be  due  to 
traumatism.  Spontaneous  rupture  of  the  uterus  in  pregnancy 
almos.*"  always  occurs  at  the   fundus,  and  frequently  at  the  pla- 


ABORTION,  MISCARRIAGE,  AND  PREMATURE  LABOR.      267 

cental  site.  The  accident  is  almost  invariably  fatal  to  both 
mother  and  child.  It  indicates  an  immediate  abdominal  section 
and  usually  a  hysterectomy.  A  very  serious  accident  of  preg- 
nancy is  detachment  of  a  normally  situated  placenta,  with  con- 
cealed internal  hemorrhage  (see  Dystocia). 

Surgical  Operations. — If  a  pregnant  woman's  life  or  health 
is  seriously  threatened  by  delay  until  the  completion  of  puerperal 
convalescence,  surgical  operations  are  justifiable,  and  permission 
may  be  given  for  their  performance  without  great  fear  of  an  abor- 
tion if  septic  infection  is  avoided.  Keen  successfully  amputated 
the  thigh  at  the  hip-joint  for  sarcoma  in  a  woman  five  months 
pregnant,  without  interrupting  gestation.  Tumors  of  the  pelvic 
organs  may  be  excised  with  no  more  risk  of  abortion  than  any 
woman  runs  (twenty  per  cent).  It  is  even  possible  to  remove  a 
myoma  from  the  uterine  wall  without  inciting  uterine  contractions. 
I  had  the  privilege  of  assisting  Dr.  \Vm.  J.  Ta\'lor  in  a  myomec- 
tomy on  a  woman  four  months  pregnant.  The  tumor  was  enu- 
cleated from  the  uterine  wall,  leaving  a  raw  surface  as  large  as 
the  outspread  hand.  The  woman  was  prematurely  delivered,  but 
it  was  some  time  after  the  operation,  which  apparently  did  not 
cause  the  miscarriage.  In  nervous  and  irritable  women,  how- 
ever, slight  operations,  such  as  the  extraction  of  a  tooth,  may  in- 
terrupt gestation.  The  proper  course,  naturally,  is  to  avoid 
operative  interference  in  the  pregnant  woman,  if  it  can  be  deferred 
without  serious  detriment  to  her.  If,  on  the  contrary,  there  is 
a  positive  indication  for  immediate  operation,  it  should  be  under- 
taken without  hesitation. 


ABORTION,  MISCARRIAGE,  AND  PREMATURE  LABOR. 

The  term  "abortion"  is  applied  to  the  e.xpulsion  of  the  ovum 
before  the  fourth  month.  Premature  labor  signifies  the  birth  of 
a  fetus  that  is  viable.  For  the  expulsion  of  the  ovum  during 
the  intervening  time  from  the  fourth  to  the  sixth  month  of  ])reg- 
nancy  a  distinctive  term  is  needed,  as  the  process,  in  combining 
some  of  the  features  of  both  abortion  and  premature  labor,  pre- 
sents a  clinical  picture  different  from  either  of  them.  To  denote 
the  interruption  of  pregnancy  at  this  time  the  word  "miscarriage" 
is  used.' 

'  In  speaking  to  patients  the  word  "  abortion  "  sliould  not  be  used  by  the  physi- 
cian :  it  is  resented  as  implying  something  criminal.  Miscarriage  means  to  the  laity 
the  interruption  of  pregnancy  before  the  viability  of  the  fetus. 


268  PREGNANCY. 

The  Causes  of  Premature  Expulsion  of  the  Ovum. — Many 
of  the  conditions  which  interrupt  the  course  of  pregnancy  have 
been  referred  to.  The  death  of  the  fetus  ;  abnormahties  and 
diseases  of  the  membranes,  including  the  deciduae  ;  pathological 
conditions  of  the  placenta  and  apoplexies  of  the  ovum  ;  trau- 
matism and  certain  diseases  of  the  mother  have  all  been  noticed. 
But  the  maternal  diseases  have  been  regarded  chiefly  as  to  their 
effect  directly  upon  the  embryo,  fetus,  or  ovum.  There  are, 
however,  certain  conditions  of  the  mother  having  as  their  primary 
effect  the  active  contraction  of  the  uterine  muscle,  which  results 
secondarily  in  the  premature  expulsion  of  the  ovum,  although  the 
latter  may  be  normal  in  every  respect.      Under  this  head  come  : 

Irritable  Uterus. — From  clinical  observation  one  must  feel  in- 
clined to  ascribe  to  every  uterus  a  special  temperament,  which, 
as  the  case  may  be,  is  irritable,  equable,  or  apathetic.  It  is 
notorious  that  some  pregnant  women  are  liable  to  lose  the 
product  of  conception  from  a  trivial  cause.  A  long  walk,  coitus, 
congestion  of  the  pelvis  from  any  cause,  ovaritis,  irritation  of  the 
breasts  or  nipples,  the  extraction  of  a  tooth,  irritation  of  the 
vulva,  a  dose  of  some  mild  purgative,  the  jolting  of  a  carriage  ; 
a  misstep,  especially  while  descending  a  staircase  ;  not  to  mention 
a  sea-bath,  exercise  on  horseback,  or  dancing,  have  been  followed 
by  expulsion  of  the  ovum.  The  mere  sight  of  another  woman 
in  labor  has  been  sufficient  cause  for  abortion  in  some  nervous 
women.  In  case  the  disposition  of  the  woman  to  abort  is  known, 
the  greatest  care  must  be  exercised  to  guard  her  from  anything 
which  might  stimulate  uterine  contractions,  and  at  the  time  corre- 
sponding to  the  menstrual  period,  when  the  uterus  is  particularly 
irritable  and  prone  from  habit  to  contract,  the  precautions  must 
be  doubled. 

The  opposite  picture,  while  not  so  familiar,  is  occasionally 
seen.  Some  women  can  make  the  most  violent  exertion,  can 
receive  the  roughest  treatment,  without  bringing  pregnancy  to 
an  end.  English  women  have  followed  the  hounds  over  the 
most  difficult  country  in  the  early  months  of  pregnancy  without 
aborting.  Sounds  have  been  introduced  into  the  pregnant  uterus; 
intra- uterine  injections  have  been  given  ;  ^  strong  applications 
have  been  made  to  the  endometrium ;  trocars  have  been  plunged 
through  the  uterine  wall ;  ^  a  pregnant  woman  has  been  thrown 
violently  from  her   carriage;  ^     another  fell  from  a  third-story 

1  Scanzoni,  "  Lehrbuch  d.  Geb.,"  Wien,  1867,  p.  83. 

2  Many  cases  are  reported  of  tapping  a  uterus  distended  by  hydraranios  in  mis- 
take for  an  ovarian  cyst  or  ascites. 

3  Tarnier  and  Cazeaux,  8th  ed.,  p.  567.      Also  two  of  my  patients. 


ABORTION,  MISCARRIAGE,  AND  PREMATURE  LABOR.     269 

window,  fracturing  her  skull  and  breaking  a  leg;^  a  young  girl, 
five  months  pregnant,  cast  herself  from  the  Pont  Neuf  into  the 
Seine ; '  in  another,  fifteen  leeches  were  applied  to  the  cervax  of  a 
pregnant  uterus ;  Emmet's  operation  has  been  performed  upon 
the  cervix  during  the  second  month  of  pregnancy;  ovariotomy 
and  other  serious  surgical  operations  have  been  repeatedly 
performed,  the  spleen  has  been  ruptured  by  violence  and 
has  been  extirpated,^ — all  without  inducing  abortion  or  pre- 
mature labor. 

Spasmodic  Muscular  Action  in  the  Mother  as  a  Cause  of  Prema^ 
lure  Expulsion  of  the  Ovum. — Pregnant  women  affected  with  cho- 
rea, eclampsia,  uncontrollable  vomiting  or  coughing,  epileptic, 
hysterical,  or  cholemic  convulsions,  or  with  tetany,  are  very  liable 
to  expel  the  product  of  conception  prematurely. 

Chorea. — Less  than  half  of  the  women  affected  with  cho- 
rea gravidarum  go  to  term.  Of  57  cases  collected  by  Barnes, 
only  22  completed  the  full  time  of  pregnancy.  Bamberg's 
statistics  of  64  cases  show  33  arrived  at  term,  and  Spiegelberg, 
in  69  cases,  saw  only  29  delivered  of  mature  infants.* 

In  a  case  under  my  observation  the  uterine  muscle  toward  the 
end  of  pregnancy  seemed  to  take  part  in  the  choreic  movements 
that  convulsed  the  muscles  of  the  extremities.  Through  the  ab- 
dominal wall  the  uterus  could  be  felt  firmly  contracting  at  intervals 
of  not  more  than  a  minute.  Every  contraction  was  extremely 
painful,  but  during  the  four  days  that  this  condition  of  the  uterus 
lasted  the  os  showed  no  signs  of  dilatation.  The  suffering  finally 
became  so  great  that  labor  was  induced.'^ 

Eclampsia. — The  eclampsia  of  pregnancy  in  the  great  majority 
of  cases  determines  the  premature  expulsion  of  the  ovum.  Fre- 
quently, no  doubt,  the  life  of  the  fetus  is  first  destroyed;  often, 
however,  the  immediate  effect  is  seen  in  expulsive  efforts  of  the 
uterus,  due  to  asphyxia  of  the  organ,  to  the  irritating  effect  of  the 
toxemia,  or  perhaps  to  the  fact  that  the  uterine  muscle  shares  in 
the  convulsive  action  of  the  whole  muscular  system. 

Uncontrollable  Vomiting  and  Coughing. — The  constant  violent 
action  of  the  diaphragm  in  cases  of  uncontrollable  vomiting  dur- 
ing pregnancy  often  leads  to  the  expulsion  of  the  ovum.  Of 
51   cases   of    uncontrollable  vomiting  collected    by   Gueniot,    20 

1  A  patient  of  mine  in  the  Philadelphia  Hospital.  She  recovered  from  her 
injuries,  received  at  the  fifth  month  of  pregnancy,  and  was  delivered  at  term. 

2  Juillard,  "  Nouvelles  Archives  d'Obstet.  et  de  Gynec,"  18S6,  p.  1645. 

3  Savor,  "  Centralbl.  f.  Gyn.,"  No.  6,  1899. 
*  Herv6,  "  These  dc  Paris,"  1884. 

^  For  a  report  of  the  case  see  "Trans.  Philadelphia  Obstet.  Soc,"  Dec,  1887. 


2/0  PREGNANCY.    ' 

ended  in  abortion  or  premature  labor. ^  A  violent  and  per- 
sistent cough  is  also,  in  rare  instances,  the  cause  of  premature 
expulsion  of  the  ovum  by  the  constant  succussion  in  the  ab- 
dominal cavity. 

Epileptic,  Hysterical,  Cholemic,  and  Tetanoid  Convulsions. — 
Attacks  of  epilepsy  during  pregnancy  may  be  disastrous  to  the 
fetus,  either  killing  it  outright  or  bringing  about  its  premature 
expulsion.  Tanner  mentions  a  case  of  hysterical  convulsions 
which  was  followed  by  the  expulsion  of  a  dead  fetus  at  the 
seventh  month.  ^  Cholemic  convulsions  occur  more  frequently 
than  is  generally  supposed,^  and  they  always  interrupt  preg- 
nancy, either  by  the  death  of  the  mother  or  the  expulsion  of 
the  ovum.  Meinert  *  has  collected  1 1  cases  of  a  tetanoid  con- 
dition in  pregnancy,  in  6  of  which  there  was  true  tetany.  In 
2  of  the  1 1  cases  dead  children  were  born,  i  prematurely  at  the 
seventh  month,  the  other  at  term.  In  one  other  case  the  child 
was  expelled  at  the  eighth  month,  and  in  another  eleven  days 
before  term. 

Conditions  of  the  Maternal  Blood  which  Stimulate  the  Pregnant 
Uterus  to  Contract. — The  poisons  of  all  the  infectious  diseases  in 
the  maternal  blood  may  excite  active  contractions  in  the  pregnant 
uterus.  Whether  this  is  due  to  some  irritative  action  of  the  micro- 
organisms, or  to  the  development  of  the  toxins,  or  to  a  diminution 
of  the  oxygenating  power  of  the  blood,  as  yet  remains  in  doubt. 
The  last  condition  explains  the  abortions  occurring  in  pneu- 
monia, as  well  as  in  cases  of  chronic  heart  disease,  in  which  the 
circulation  is  much  interfered  with.  It  is  possible  also  that 
strong  emotions  alter  the  blood  in  some  way  that  would  accomnt 
for  the  action  of  the  uterus  when  women  have  been  terrified. 
But  it  is  more  Hkely  that  the  action  is  analogous  to  that  of  the 
rectal  and  vesical  muscles  in  cases  of  nervous  defecation  and  uri- 
nation. Baudelocque  said  in  his  lectures  that,  after  the  explo- 
sion of  the  powder-mill  of  Grenelle,  he  was  called  to'  see  sixty- 
two  women,  either  aborting  or  threatened  with  abortion.  In  all 
maternal  diseases  accompanied  by  fever  the  thermic  irritation  of 
the  uterine  muscle  might  be  responsible  for  the  expulsive  efforts 
of  the  uterus. 

Uterine  Contractions  Excited  by  an  Abnormal  Situation  or  Posi= 
tion  of  the  Uterus. — Retroflexion  and  prolapse  of  the  gravid  uterus 
may  induce  abortion,  for  the  uterus  is  unable  to  expand  properly 

1  Tarnier  et  Budin,  op.  cit.,  p.  59. 

2  "  The  Signs  and  Diseases  of  Pregnancy,"  London,  1867,  p.  304. 
^  Stumpf,  loc.  cit. 

*  "  Archiv  f.  Gyn.,"  Bd.  xxxi,  S.  444. 


ABORTIOX,    MISCARRIAGE,  AND   PREMATURE   LABOR.    27 1 

in  its  unnatural  position.      This  is  true  likewise  of  pregnancy  in 
one  horn  of  a  bicornate  uterus.  ■'^ 

Perimetritis  also,  resulting  in  adhesions  between  the  uterus 
and  neighboring  organs,  or  cellulitis,  Vv^ith  plastic  exudate  in  the 
broad  ligaments,  as  well  as  diseases  of  a  tube  and  ovary  leading 
to  adhesions,  will,  if  pregnancy  should  occur,  usually  interrupt 
its  course  by  interfering  with  the  expansion  of  the  gravid  uterus. 
Appendicitis,  with  adhesions  involving  the  uterine  adnexa,  may 
also  have  the  same  result.  Fibromyomata  of  the  uterine  wall 
may  act  in  the  same  manner,  or  else,  by  the  congestion  of  the 
organ  to  which  they  lead,  or  by  acting  as  a  mechanical  irritant, 
may  stimulate  the  uterine  muscle  to  contraction. 

Overdistention  of  the  Uterus  as  a  Cause  of  Premature  Expulsion 
of  the  Ovum. — If  the  uterus  is  unduly  distended  in  hydramnios 
or  in  cases  of  multiple  pregnancy,^  especially  when  there  are 
three  or  more  fetuses,  the  distention  of  the  muscle  may  irritate  it 
to  expulsive  efforts. 

In  twin  pregnancies,  should  one  fetus  die,  the  uterine  muscle 
is  occasionally  stimulated  to  contraction,  and  the  entire  uterine 
contents  are  cast  off,  although  the  remaining  fetus  may  be  healthy 
and  normal.  In  cows  epidemics  of  abortion  have  been  observed, 
which  have  been  attributed  to  a  specific  form  of  micro-organism, 
said  by  Franck  and  Rolofif  to  resemble  the  leptothrix  buccalis.^ 
Brocard*  has  also  called  attention  again  to  this  disease.  It  is 
improbable  that  the  same  disease  can  affect  a  woman,  but  in 
lying-in  hospitals  an  epidemic  of  abortion  or  premature  labor 
might  occur  from  septic  infection  during  pregnancy. 

Clinical  History  of  Abortion  and  Miscarriage. — Premature 
labor  is  not  referred  to.  Its  course,  management,  compHcations, 
and  after-treatment  may  be  considered  in  the  description  of  labor 
at  term,  from  which  it  does  not  materially  differ. 

The  Frequency  of  Abortion. — It  is  almost  impossible  to 
arrive  at  a  correct  estimate  of  the  frequency  of  abortion.  So 
many  women  lose  an  impregnated  ovum  at  an  early  period  of 
its  development,  when  they  are  not  conscious  of  being  preg- 
nant ;  so  many  others  fail  to  seek  medical  advice  for  an  abortion 
uncomplicated  by  hemorrhage  or  decomposition  of  retained 
secundines,  that  almost  all  the  estimates  of  the  relative  fre- 
quency of  abortion  and  labor  at  term  place  the  figure  for  the 

'  L.  Mund6,  "  Case  of  Pregnancy  in  One  Horn  of  a  Double  Uterus,  with 
Successive  Miscarriages,"  "  Araer.  Jour.  Obstetrics,"  1887,  pp.  337,  346. 

2  See  Doleris,  "  Nouvelles  Archives  d'Obst^t.  et  de  Gyndc,"  1886,  p.  318. 

3  Schroeder,  "  Geburtshulfe,"  8.  Aufl.,  1884,  p.  460. 

^  "  Recherches  sur  1'  Avortement  6pizootique  des  Vaches,"  I>roch.,  Paris,  1SS6. 


2/2  PREGNANCY.    . 

former  too  low.  Hegar  ^  says  that  one  abortion  occurs  to  every 
eight  or  ten  labors  at  term;  but  the  estimate  of  Guillemot 
and  Devilliers/  of  one  abortion  to  every  four  or  five  pregnancies, 
is  more  correct.  Priestley  '  found  that  400  women,  among  whom 
there  had  been  2325  pregnancies,  gave  a  return  of  542  abortions, 
or  about  one  abortion  to  every  four  pregnancies.  My  own  case- 
books also  show  this  proportion. 

Clinical  Phenomena  of  Abortion. — -The  main  clinical  phe- 
nomena of  abortion  are:  (i)  Hemorrhage,  (2)  pain,  and  (3)  the 
expulsion  of  more  or  less  characteristic  portions  of  an  impreg- 
nated ovum.  But  these  symptoms  are  rarely  all  manifested  in  a 
typical  manner  in  every  case.  Pain  may  be  absent,  hemorrhage 
not  excessive,  and  the  whole  ovum  when  cast  off  so  small  that  it 
escapes  unnoticed  among  the  clots  of  blood  that  are  discharged 
from  the  uterus.  Such  cases  occur  sjiortly  after  conception,  and 
often  pass  for  disordered  menstruation,  while  the  fact  that  preg- 
nancy had  begun  is  not  suspected. 

The  duration  of  abortion  varies.  The  French  speak  of  an 
avortement  instantane  and  Cazeaux  gives  an  example  of  a  woman, 
who  fell  upon  her  buttocks,  and,  on  rising,  found  on  her  linen  con- 
siderable blood  and  a  six-weeks'  ovum.  In  some  cases  the  expul- 
sion of  the  ovum  m_ay  occupy  about  the  time  consumed  in  a  normal 
labor,  but  very  frequently  the  process  is  much  slower.  Days,  and 
even  weeks,  may  be  required  for  the  uterus  to  get  rid  of  its 
contents  if  left  unaided  to  nature,  and  it  is  not  rare  for  a  fragment 
of  the  placenta  or  a  portion  of  the  uterine  decidua  to  remain 
behind  indefinitely,  firmly  attached  to  the  uterine  wall  and  often 
continuing  to  grow  and  develop,  constituting  within  the  uterus  a 
true  pathological  new  formation. 4  Of  the  two  symptoms,  pain 
and  hemorrhage,  the  former  is,  in  early  abortions,  usually  the  sub- 
ordinate one.  The  hemorrhage  is  not  often  excessive,  but  may 
become  alarming.  The  blood  is  not  expelled  in  a  steady  flow, 
but  from  time  to  time  as  coagula.  When  the  uterus  discharges 
its  contents  the  appearance  of  the  substance  expelled  differs 
as  the  ovum  is  cast  off  entire  with  its  shaggy,  chorional  coat,  or 
surrounded  by  the  decidua,  which  is  often  much  thickened ;  as 
the  embryo,  enveloped  by  its  amnion,  is  extruded  without  the 
decidua  and  chorion,  or  as  the  embryo,  its  delicate  umbilical 
cord  being  ruptured,  is  expelled  alone.  The  appearance  of 
the  embryo  varies,  of  course,  with  the  different  periods  of  preg- 

1  "  Beitrage  zur  P.ithologie  des  Eies,"  '•  Monats.  f.  Geburtsh.,"  Bd.  xxxi,  S.  34. 

2  Tarnier  et  Budin,  oj).  ciL,  p.  474- 

^  "Pathology  of  Intra-uterine  Death,"  London,  1887,  p.  S. 
^  A  condition  described  under  the  names  "placental  polyp,"  "polypoid  hema- 
tomata." 


AB  OR  TIOiV,  MISCARRIA  GE,  AND  PRE  MA  TURE  LABOR.     273 


Fig.   180.  —  tetus  in  its  membranes. 


Fig.  181. — Dead  embryo  in  a  capsule  of  thickened  decidua.      Absorption 
of  the  liquor  amnii. 


18 


Fig.   182. — Young  embrj-o,  thickened  decidua,  and  ruptured  ovum. 


^H    'V*t  IHfc      .-ct^^l 

^^V/             ''\if!^^^-J^'8K!W 

H      ^               ^^H^l 

^Hi                          ''^'l^^l 

1^^^^ 

Fig.   183. — Ruptured  membranes,  embn>-o,  and  newly  formed  placenta. 


ABORTION,    MISCARRIAGE  AND   PREMATURE   LABOR.    275 

nancy:  if  still  inclosed  in  its  amniotic  sac,  a  thin-walled,  trans- 
parent vesicle  may  be  found  floating  in  the  blood  or  imbedded  in 
a  clot,  and  within  the  sac  the  embryo  is  seen  floating  in  the  licjuor 
amnii.  In  other  cases  the  ovum  resembles  a  ball  of  flesh,  which, 
on  being  opened,  discloses  an  embryo  confined  within  a  sac 
with  very  thick  walls,  composed  mainly  of  greatly  hypertrojjhied 
decidua.  Or,  again,  the  substance  expelled  from  the  uterus 
may  be  a  fleshy  mass,  the  deciduous  membrane,  in  shape  a 
cast  of  the  uterine  cavity,  within  which  there  is  an  empty  cavity. 
The  embryo  in  these  cases  has  either  died  and  been  absorbed, 


Fig.  184. — Embiyo  of  about  four  weeks,  with  its  membranes  entire. 

or  else  has  been  previously  cast  off  unnoticed  in  the  bloody  dis- 
charge. 

If  the  ovum  proper  is  cast  off  entire, — that  is,  with  its  cho- 
rional  covering  intact,  without  adherent  shreds  of  deciduous 
membrane, — it  presents  an  appearance  quite  characteristic,  espe- 
cially if  floated  in  water  ;  the  chorional  villi  show  to  the  best 
advantage,  giving  the  ovum  much  the  appearance,  except  for  its 
color,  of  a  chestnut-bur. 

Most  frequently  it  is  the  embryo  alone,  or  at  most  the  ovum, 
in  whole  or  in  part,  covered  often  by  the  ovular  decidua,  that  is 
discharged,  while  the  uterine  decidua  remains  behind  within  the 
uterus.* 

The  retention  of  this  membrane  after  abortion  can  not  be 
regarded  wdth  indifference.  The  thickened  uterine  decidua  is 
infected  and  decomposes,  or  else  portions  of  the  decidua  attract 
an  increased  blood-supply,  retain  their  original  development, 
and  even  increase  in  size,  forming  new  growths  within  the  uterus 
which  give  rise  to  frequent  and  alarming  hemorrhages  or  to  \)QX- 
sistent  metrorrhagia. 

It  is  this  complication  of  abortion  that  often  makes  the  jjrog- 
nosis  uncertain,  and  is  the  main  factor  in  raising  the  mortality 

'  Diihrssen,  ''  Ziir  Pathoiogie  und  Therapie  des  Abortus,"  "Archiv  f.  Gyn.," 
Jid.  xxxi,  H.  3. 


2/6  PREGNANCY. 

after  abortions  as  high  as  that  of  childbirth  at  term.  Maygrier 
saw  four  deaths  in  698  spontaneous  abortions,  but  25  in  44  criminal 
abortions.^  In  the  Rotunda  Hospital  of  Dublin,  during  the 
mastership  of  Dr.  Johnston,  234  abortions  occurred,  with  but  i 
death,  and  that  from  heart  disease.^  But  of  120  cases  treated 
in  the  cHnic  and  polyclinic  of  the  Charite  in  Berlin,  2  died.^  Of 
82  abortions  in  the  Obstetrical  and  Gynecological  Institute  of 
Florence,*  5  resulted  fatally  to  the  women, — a  death-rate  of  6  per 
cent.  In  the  Charite  at  Paris  (1883-86)  there  were  57  cases  of 
abortion  without  a  death;  and  in  the  Maternite,  153  cases  with  i 
death  (Tarnier).  In  the  Woman's  Hospital  of  Bern,  of  484 
abortions,  4  ended  fatally.^  In  74  protracted  abortions  the 
uterine  cavity  was  found  infected  in  every  case  by  pathogenic 
micro-organisms.  In  12  cases  there  had  been  no  digital  examina- 
tion." In  15,000  abortions  treated  in  the  University  clinic  of 
Berlin,  450  women  were  seriously  ill  and  94  died.'' 

Diagnosis. — It  may  be  necessary  in  cases  of  suspected  abor- 
tion to  determine  the  existence  of  pregnancy ;  that  fact  being 
established,  it  becomes  necessary  to  distinguish  between  threat- 
ened abortion,  inevitable  abortion,  and  an  abortion  partially  or 
wholly  accomplished. 

The  Diagnosis  of  Threatened  Abortion. — If  a  patient  presents 
a  history  of  suppression  of  the  menses;  if  she  has  been  exposed  to 
the  possibility  of  impregnation;  \i  there  are,  in  short,  the  signs 
of  early  pregnancy,  and  a  hemorrhage  occurs  from  the  uterus, 
associated  with  more  or  less  pain,  a  threatened  abortion  is 
probable.  Irregularities  in  menstruation,  the  suppression  of  the 
function  from  causes  other  than  pregnancy,  and  its  reestablish- 
ment  by  a  profuse  flow,  accom_panied  by  pain,  arouse  a  suspicion 
of  abortion.  In  these  cases,  however,  the  signs  of  pregnancy  are 
absent  and  the  os  is  not  patulous.  But  if  the  symptoms  should  be 
due  to  an  effort  of  the  uterus  to  expel  a  polypoid  tumor,  the  case 
may  so  closely  resemble  one  of  abortion  that  the  diagnosis  is  only 
made  after  the  expulsion  of  the  uterine  contents  or  the  dilatation 

1  Doleris,  "  Statistique  sur  I'Avortement,  Ann.  de  Gyn. ,"  April,  1905. 

2  Lusk's  "  Obstetrics,"  1886,  p.  313. 

^  Diihrssen, /oiT.  cit.  This  same  author  mentions  the  statistics  of  520  cases  of 
abortion  collected  in  the  inaugural  thesis  of  Lechler  (Berlin).  Half  of  these,  treated 
by  active  interference,  showed  4  deaths, — 3  from  intercurrent  affections,  i  the  result 
of  abortion. 

*Fasola,  "82  aborti  nel  trienno,  1883-S5,"  "  Annali  di  Ostet.  e.  G\necol.," 
March,  1887. 

5  "Swiss  Dissertations,"  F.  Moser,  Bern,  1900. 

6  Hellendal,  "  Zentralbl.  f.  Gyn.,"  No.  27,  1905. 

'' Seegert,  "  Ztschr.  f.  Geb.  u.  Gyn.,"  B.  Ivii,  H.  3,  p.  344. 


ABORTION,   MISCARRIAGE,   AND   PREMATURE   LABOR.    2/7 

of  the  OS.     In  cases  of  doubt  the  diagnosis  should  rest  on  abortion 
and  tlie  woman  should  be  treated  accordingly. 

The  Diagnosis  of  Inevitable  Abortion. — It  is  always  desirable 
to  determine  when  a  threatened  abortion  becomes  inevitable,  for 
if  its  prevention  is  no  longer  possible,  the  treatment  should  be 
radically  altered.  Unfortunately,  the  signs  which  usually  denote 
an  unavoidable  expulsion  of  the  ovum  can  not  always  be 
depended  upon.  If  there  is  persistent  hemorrhage,  abortion 
will  usually  occur,  but  even  in  spite  of  a  bleeding  which  may 
continue  for  a  considerable  time  or  return  at  intervals  during 
the  whole  duration  of  gestation,  the  pregnancy  may  go  on  to 
term.  If  the  cervix  becomes  markedly  softened  and  the  os 
dilates,  the  ovum  will  ordinarily  be  cast  off;  and  yet  the  os  has 
dilated  sufficiently  to  admit  two  fingers,  but  has  again  retracted, 
and  pregnancy  has  pursued  its  course.  If  portions  of  the  uterine 
contents  should  be  expelled,  it  would  seem  that  abortion  was 
surely  inevitable ;  but  Playfair,  Charpentier,  and  Doleris  have 
reported  cases  in  which  pieces  of  decidua  were  expelled  from  the 
uterus  without  the  interruption  of  pregnancy.  In  Playfair's  case 
four  or  five  fragments  of  decidua,  each  as  large  as  a  fifty-cent 
piece,  were  cast  off  in  the  third  month  of  pregnancy  as  a  result 
of  the  introduction  of  a  sound  into  the  uterus  ;  but  the  woman 
went  on  to  term.  The  only  two  conditions  which  can  be  said 
to  render  the  abortion  almost  inevitable  are  the  rupture  of  the 
membranes  and  the  death  of  the  embryo  ;  but  even  were  it  pos- 
sible to  ascertain  with  certainty,  during  the  early  months  of 
pregnancy,  that  the  membranes  were  ruptured  or  that  the  embryo 
was  dead,  cases  might  be  recalled  in  which  the  liquor  amnii  was 
resuppHed  after  puncture  of  the  pregnant  uterus  with  a  trocar 
(Chiara),  and  after  rupture  of  the  membranes,  and  there  has  been 
a  retention  of  the  ovum  after  the  death  of  the  embryo  for  months 
or  for  an  indefinite  number  of  years.  If  the  hemorrhage  is  persis- 
tent; if  the  OS  dilates  ;  if  there  is  felt  presenting  within  the  os  a 
cystic  tumor — the  ovum  ;  ^  if  the  pain  is  considerable;  and,  above 
all,  if  portions  of  the  ovum  are  expelled,  abortion  may  be  pro- 
nounced inevitable.  Tarnier  ^  calls  attention  to  a  sign  which  is 
valuable  as  indicating  an  unavoidable  abortion.  This  is  the 
effacement  of  the  acute  angle  formed  anteriorly  between  the  neck 
and  body  of  a  pregnant  uterus.  The  disappearance  of  this  angle 
indicates  a  contraction  of  the  longitudinal  fibers  of  the  uterus  and 
a  descent  of  the  ovum. 

1  It  is  well  to  bear  in  mind  in  this  connection  the  possibility  of  the  cervical 
pregnancy  of  Rokitansky,  already  referred  to,  of  which  several  cases  have  been 
reported. 

^  Tarnier  and  Caseaux,  vol.  i,  p.  574- 


278  PREGNANCY. 

The  Diagnosis  of  an  Abortion  Partially  or  Wholly  Accomplished. 

— It  is  always  important  to  determine,  in  a  case  diagnosticated  as 
one  of  abortion,  whether  a  part  or  the  whole  of  the  uterine  con- 
tents has  been  expelled.  It  is  necessary  to  examine  everything 
discharged  from  the  uterus;  the  clots  should  be  floated  in  water, 
and  should  be  carefully  teased  apart,  when  an  embryo,  alone  or 
enveloped  by  its  membranes,,  may  be  discovered.  But  frequently 
the  embryo  and  ovum  are  so  small  that  they  are  lost  in  the  com- 
paratively great  volume  of  blood  that  surrounds  them,  or  the 
discharges  are  removed  from  the  patient  and  are  not  preserved. 
In  such  cases  an  internal  digital  examination  ordinarily  serves 
to  determine  the  true  nature  of  the  case.  The  os  is  usually 
patulous;  the  finger,  passing  into  the  cavity  of  the  uterus, 
detects  shreds  of  deciduous  membrane  more  or  less  closely  at- 
tached to  the  uterine  wall,  and  often  a  placenta,  still  adhe- 
rent, or  some  portions  of  the  fetal  membranes  may  be  plainly 
distinguished.  If  the  abortion  has  been  wholly  accomplished, 
— that  is,  if  all  the  uterine  contents,  including  the  hypertro- 
phied  decidua,  have  been  completely  expelled, — the  uterus  is 
firmly  contracted,  the  os  is  small,  and  a  digital  examination 
of  the  uterine  cavity  is  difficult  or  impossible.  The  diagnosis 
must  depend  upon  the  history  of  the  case,  upon  the  examination 
of  the  discharge,  upon  the  enlarged  uterus, — which  does  not  at 
once  return  to  its  normal  size, — upon  the  lochial  discharge,  and 
upon  the  establishment  of  the  milk  secretion.  The  last  phe- 
nomenon is  all  the  more  marked  the  later  the  date  of  pregnancy 
at  which  abortion  or  miscarriage  occurs,  and  is  more  evident  in 
multiparae  than  in  primiparae  ;  but  Budin  has  observed  a  young 
girl  in  whom  the  menses  were  suppressed  for  only  twenty  days, 
and  then  returned  as  a  profuse  flow,  who  exhibited  shortly  after- 
ward all  the  signs  of  commencing  lactation. 

In  some  cases  the  disappearance  of  all  the  presumptive  signs 
of  pregnancy,  which  had  been  before  well  marked,  would  justify 
the  opinion  that  an  abortion  had  occurred  ;  but  it  might  denote 
nothing  more  than  the  death  of  the  embryo,  which  can  be  re- 
tained within  the  uterus  for  varying  periods  of  time,  and  when 
cast  off  may  give  rise  to  unjust  suspicions  as  to  the  woman's 
moral  character.  Thus,  if  a  woman  whose  liusband  has  been 
absent  many  months  should  expel  from  her  uterus  an  embr}^o 
corresponding  perhaps  to  the  second  month  of  intra-uterine 
life,  it  by  no  means  invariably  follows  that  she  has  been  un- 
faithful 

Finally,  if  in  the  early  months  of  pregnancy  there  is  hemor- 
rhage and  a  discharge  of  deciduous  membrane,  it  is  always  wise 


ABORTION,    MISCARRIAGE,   AND   PREMATURE   LABOR.    279 

while  making  the  digital  examination,  to  feel  on  either  side  of  the 
uterus  for  a  tumor  that  might  indicate  a  tubal  pregnancy,  and  to 
inquire  for  the  characteristic  pain  of  that  condition.  A  large 
proportion  of  the  cases  of  extra-uterine  pregnancy  in  the  author's 
case-books  were  mistaken  by  their  medical  attendants  for  an  in- 
complete abortion. 

Prognosis  of  Abortion  and  Miscarriage. — The  destruction 
of  the  embryo  is  inevitable.  Statistics  have  been  given  show- 
ing that  every  abortion  or  miscarriage  entails  a  risk  upon  the 
woman.  The  hemorrhage,  if  rarely  so  great  as  to  be  immedi- 
ately fatal,  may,  by  its  persistence,  so  weaken  a  woman  that 
she  quickly  succumbs  if  attacked  by  an  intercurrent  affection, 
or  the  syncope  produced  by  loss  of  blood  may  favor  the  forma- 
tion of  heart-clot.  The  retention  of  masses  of  decidua  or  of 
placenta  is  often  followed  by  their  decomposition,  by  chronic 
salpingo-oophoritis,  or  even  by  fatal  septicemia.  Tetanus 
is  another  complication  which,  in  rare  cases,  helps  to  raise  the 
mortality.^  Criminal  abortions,  with  the  additional  risk  of  trau- 
matism from  the  unskilful  use  of  instruments,  and  the  probability 
of  infection  from  unclean  hands  and  implements,  would  probably 
show  a  very  high  rate  of  mortahty  if  it  were  possible  to  collect 
accurate  statistics.  The  prognosis  of  abortion  depends  in  great 
part  upon  the  treatment.  If  every  case  could  be  treated  by 
an  aseptic  and  skilful  curettage,  the  mortahty  of  abortion  would 
be  nil. 

Treatment. — If  a  pregnant  woman  presents  any  of  the  con- 
ditions which  a  physician's  experience  or  knowledge  teaches  him 
may  lead  to  the  premature  interruption  of  pregnancy,  the  treat- 
ment of  these  conditions  constitutes  the  preventive  treatment 
of  abortion.  Much  has  been  said  upon  this  subject  when 
the  diseases  of  the  embryo  and  fetus  and  of  the  ovum  were 
under  consideration.  The  proper  conduct  to  pursue  in  the 
other  complications  of  pregnancy  just  described  may  be  briefly 
indicated. 

In  cases  of  irritable  uterus  the  woman  must  be  jealously 
guarded  against  any  nervous  shock,  undue  physical  exertion, 
errors  in  diet,  sexual  intercourse — anything,  in  a  word,  that 
would  furnish  the  uterus  an  excuse  for  throwing  off  its  contents. 
In  exaggerated  cases  of  this  condition  prolonged  rest  in  bed, 
especially  at  the  time  corresponding  to  the  menstrual  periods, 
or  perhaps  for  the  whole  duration  of  pregnane}',  may  be  neces- 

1  For  twenty-one  cases  of  tetanus  alter  abortion  see  Bennington,  "  British  Gyn. 
Jour.,"  1885. 


28o  PREGNANCY. 

sary  to  secure  the  birth  of  a  mature  infant.  If  the  pregnant 
uterus  is  displaced  downward  or  backward,  it  must  be  restored 
to  its  proper  position,  and  be  kept  in  place  by  a  suitable  pessary 
or  by  tampons  until  its  increasing  size  prevents  its  displacement 
again.  Uncontrollable  vomiting  or  coughing  must  be  treated 
appropriately.  Asthma,  which  in  some  cases  determines  a  pre- 
mature interruption  of  pregnancy,  is  best  treated  by  change  of 
chmate.  1  In  general  muscular  spasms,  as  in  eclampsia,  chol- 
emia,  chorea,  epilepsy,  hysteria,  and  tetany,  the  convulsions  must 
be  combated  by  appropriate  remedies.  The  infectious  and  febrile 
diseases  of  pregnancy  must  be  managed  on  general  principles, 
without  special  regard  to  the  danger  of  abortion,  which  is  often 
unavoidable.  Chronic  metritis  and  endometritis,  fibromyoma 
of  the  uterus,  lacerated  cervix,  perimetritis  and  cellulitis,  disease 
of  a  tube  or  an  ovary,  and  appendicitis,  must  be  treated  before 
impregnation.  If,  in  spite  of  every  precaution,  the  signs  of  threat- 
ened abortion  manifest  themselves,  the  treatment  resolves  itself 
into:  (i)  The  treatment  of  threatened  abortion;  (2)  the  treat- 
ment, if  necessary,  of  inevitable  abortion;  and  (3)  the  after- 
treatment. 

The  Treatment  of  Threatened  Abortion. — The  two  main 
principles  of  the  treatment  to  avert  a  threatened  abortion 
should  be  perfect  rest  and  the  administration  of  drugs  that 
diminish  nervous  sensibility  and  weaken  muscular  action.  The 
first  can  only  be  secured  in  bed  in  a  perfectly  supine  position. 
The  room  should  be  darkened  and  kept  quiet,  that  the  rest  may 
be  mental  as  well  as  physical.  The  second  object  of  the 
treatment  is  accomplished  by  giving  opium,  bromid  of  potas- 
sium, and  chloral.  Opium  enjoys  a  well-deserved  reputation 
in  these  cases.  It  may  be  administered  by  the  mouth  as  lauda- 
num, hypodermatically  as  morphin,  or,  best,  by  the  rectum  as 
extract  of  opium  in  suppositories.  Women  on  the  verge  of  abor- 
tion usually  display  a  remarkable  tolerance  of  opium,  and  to  be 
effective  the  dose  must  often  be  large.  As  much  as  a  dram  (3.9 
gm.)  or  more  of  laudanum  has  been  given  within  twenty-four 
hours  without  ill  effect,  but,  of  course,  the  patient  must  in  such 
cases  be  carefully  observed.  With  the  opium  it  is  often  an 
advantage  to  combine  moderate  doses  of  chloral  and  bromid  of 
potassium.  Viburnum  prunifolium^  has  been  much  vaunted  as 
almost  a  specific  in  the  prevention  of  abortion,  and  its  use  has 
become  general  throughout  America.     The  verdict  is  favorable. 

1  See  note  by  Harris  to  Playfair's  "  Midwifery,"  p.  243. 

^  Jenks,  "Viburnum  Prunifolium,"  "Trans.  Amer.  Gyn.  Society,"  vol.  i,  p. 
130. 


ABORTION,   MISCARRIAGE,   AND   PREMATURE   LABOR.    28 1 

It  may  be  given  in  the  form  of  a  fluid  extract,  in  teaspoonful 
doses  three  times  a  day.  My  routine  medicinal  treatment  is  a 
suppository  of  a  grain  (0.065  gm.)  of  the  extract  of  opium  morn- 
ing and  evening,  and  a  dram  (3.75  c.c.)  of  the  fluid  extract  of 
viburnum  three  times  a  day.* 

Treatment  of  Inevitable  Abortion. — As  soon  as  all  hope 
of  arresting  the  abortion  is  destroyed  by  the  appearance  of  signs 
pointing  to  the  unavoidable  expulsion  of  the  uterine  contents,  the 
treatment  must  be  radically  altered.  Absolute  rest  is  no  longer 
necessary,  while  the  administration  of  drugs  that  diminish  sensi- 
bility and  weaken  muscular  action  is  positively  harmful,  for  it 
prolongs  a  process  which  in  the  interests  of  the  patient  is  best 
completed  as  speedily  as  possible.  But  days  often  elapse  before 
the  greater  part  of  the  uterine  contents  is  expelled,  and  it  may  be 
weeks  before  she  is  rid  of  the  thickened  decidua,  which  usually 
remains  behind,  or  of  the  adherent  placenta,  which  is  often  retained 
in  the  uterus  after  the  escape  of  the  embryo  and  the  remainder  of 
the  ovum ;  and  all  this  time  there  may  be  recurring  hemorrhages 
of  an  alarming  character  or  a  constant  dribbling  of  blood.  The 
lochial  discharge  is  profuse,  brown  in  color,  and  probably  foul- 
smelling.  In  such  a  case  the  evacuation  of  the  uterus  must  be 
considered. 

If  the  hemorrhage  is  profuse  before  the  os  is  at  all  dilated  or 
any  portion  of  the  ovum  is  discharged,  there  is  no  difference  of 
opinion  as  to  the  necessity  of  controlling  the  bleeding.  This  is 
best  effected  by  a  vaginal  tampon  of  sterile  or  iodoform  gauze. 
A  Sims  speculum  facilitates  its  introduction. 

The  tampon  should  be  removed  after  twelve  or  t\vent)^-four 
hours,  and  replaced  by  a  fresh  one  if  necessary;  often  as  the  first 
tampon  is  removed,  the  ovum  or  fetus  comes  with  it  and  the 
immediate  symptoms  may  in  great  part  subside.  But  the  uterus 
may  not  yet  be  empty;  in  the  early  months  the  large  mass  of 
decidua  is  almost  entirely  retained  ;  later,  the  placenta  is  fre- 
quently retained.  Whether  to  treat  the  case  expectantly  until 
serious  symptoms  develop,  or  to  remove  at  once  the  substances 
in  the  uterus  which  may  give  rise  to  future  compHcations,  is  a 
problem  that  must  frequently  confront  every  practitioner.  In  the 
hands  of  a  general  practitioner  without  special  knowledge  of 
gynecological  technic,  the  best  results  are  probably  secured  by 
the  expectant  treatment,  so  long  as  there  is  no  fever,  no  excessive 
hemorrhage,  or  no  odor  of  putrefaction.  In  the  hands  of  a 
trained  gynecologist  the  best  and  safest  treatment  of  an  abortion 

1  Negri  has  recommended  large  doses  of  asafetida  if  there  had  previously  been 
a  tendency  to  abort  or  to  give  birth  to  dead  children. 


282  PREGNANCY.  ' 

is  an  aseptic  evacuation  of  the  uterus  by  a  placental  forceps,  the 
finger,  or  a  curet. 

Expectant  Treatment. — When  an  abortion  becomes  inevitable, 
ergot  may  be  substituted  for  the  drugs  that  have  been  em- 
ployed to  inhibit  muscular  action,  but  it  should  be  remembered 
that  the  prolonged  use  of  ergot  in  full  doses  complicates  the  case 
if  later  it  is  found  necessary  to  evacuate  the  uterus,  and  the  drug 
itself  may  cause  retention  of  the  ovum  by  constricting  the  cervix. 
If  there  is  much  bleeding,  tampons  are  to  be  used  in  the  manner 
already  indicated,  and  renewed  every  twelve  hours  until  the  ovum 
is  expelled,  or  else  so  well  separated  from  the  uterine  wall  that 
it  may  be  gently  expressed  or  easily  extracted  by  the  fingers. 
The  greatest  care  must  be  exercised  to  avoid  rupture  of  the 
membranes,  which  will  probably,  lead  to  the  retention  of  a  por- 
tion of  the  ovum,  whereas  its  expulsion  as  a  whole  is  particu- 
larly desirable  in  cases  managed  expectantly.  If  a  part  of  the 
embryo  or  its  appendages  remain  behind  in  the  uterus,  the 
woman  is  kept  quiet  in  bed  and  small  doses  of  ergot  are  adminis- 
tered. The  vagina  and,  if  possible,  the  uterine  cavity  are  kept 
clean  by  douches  of  sterile  water.  If  the  discharge  becomes  foul, 
the  temperature  rises,  or  hemorrhage  occurs,  the  uterine  cavity 
must  be  evacuated.     The  technic  is  described  later. 

Active  Treatment. — The  tampon  is  used  to  control  bleeding. 
When  the  dilatation  of  the  os  is  sufficient  to  admit  a  finger, 
efforts  are  made,  in  early  abortions,  to  turn  out  the  ovum  by 
sweeping  the  finger  around  it,  and  then  extracting  it  with  the 
finger  hooked  behind  it ;  or  Hoennig's  method  of  expression 
may  be  tried.  ^  These  methods  are  most  successful  when 
the  ovum  is  lodged  in  the  cervical  canal  and  lower  uterine 
segment,  its  escape  being  prevented  by  an  undilated  external  os. 
The  hemorrhage  is  usually  profuse.  The  ovum  being  wholly  or 
in  part  expelled,  everything  left  behind  in  the  uterine  cavity, 
whether  thickened  decidua  or  placental  tissue,  must  be  extracted. 
For  an  adherent  placenta  nothing  is  better  than  the  finger,  which 
can  be  made  to  reach  the  fundus  by  pressing  the  uterus  down 
from  above  through  the  abdominal  walls,  the  patient  being 
anesthetized  if  necessary.  The  placenta  is  peeled  off  from  the 
uterine  wall,  and  afterward  easily  extracted.  So  much  force  is 
often  necessary  to  do  this  that  the  use  of  an  unyielding  and 
insensible  instrument  is  not  advisable.  To  clear  out  the  thickened 
decidua,  which  almost  invariably  remains  behind  in  early  abor- 
tions, nothing  is  so  good  as  a  broad  dull  curet.     Duhrssen  has 

1  The  uterus  is  squeezed  between  the  fingers  in  a  combined  examination,  and 
the  uterine  contents  are  pressed  out  as  a  stone  is  expressed  from  a  cherry. 


ABORTION,    MISCARRIAGE,   AND   PREMATURE   lABOR.    283 

demonstrated  that  the  decidua  removed  from  the  uterus  in  this 
manner  is  not  roughly  torn  off,  but  is  separated  in  a  natural 
manner  in  the  cellular  layer.  An  indispensable  adjuvant  to  the 
curet  is  Emmet's  curetment  forceps,  used  as  a  placental  forceps, 
to  extract  fragments  of  decidua  loosened  by  the  curet.  If  the 
OS  is  so  retracted  that  neither  a  finger  nor  an  instrument  can  be 
inserted,  the  introduction  of  Hegar's  graduated  cervical  bougies 
the  use  of  branched  dilators  or  of  a  metranoicter  for  twelve  hours 
obviates  the  difficulty. 

After  the  uterine  cavity  is  evacuated,  it  should  be  irri- 
gated.^ 

The  After=treatment  of  Abortion. — If  active  treatment  has 
been  pursued,  the  after-treatment  is  simple,  for  the  lochial  dis- 
charge is  slight  and  the  involution  of  the  uterus  rapid.  Until 
involution  is  perfected  the  woman  should  be  confined  to  bed. 
It  is  never  safe,  even  in  the  earliest  cases,  to  allow  her  to  get 
up  in  less  than  a  week  or  ten  days.  The  after-treatment 
when  an  expectant  plan  has  been  pursued  has  already  been 
indicated.  Should  septicemia  develop,  it  is  treated  as  after 
deUvery  at  term. 

Missed  Abortion. — By  this  term  is  meant  the  death  of  the 
embryo,  threatened  abortion,  the  subsidence  of  symptoms,  and 
the  retention  of  the  ovum  for  a  varying  length  of  time.^  Missed 
abortion  may  give  rise  to  undeserved  suspicions  of  a  woman's 
virtue  or  to  ludicrous  mistakes  in  diagnosis.  I  was  called  in  con- 
sultation to  see  a  young  woman  who  discharged  at  term  an  ovum 
about  the  size  of  a  lemon  retained  in  utero  some  seven  months  after 
the  death  of  the  embryo.  The  young  wife  and  her  husband  were 
wealthy  and  heartily  welcomed  the  prospect  of  a  child.  They  had 
provided  an  elaborate  and  expensive  outfit  for  the  baby,  includ- 
ing a  coach.  At  the  end  of  nine  months  from  the  date  of  the 
last  normal  menstruation,  labor-pains  appeared.  The  family 
physician  made  repeated  examinations  and  assured  the  husband 
and  wife  that  the  progress  was  satisfactory.  At  length,  after 
twenty-four  hours  of  hard  pains,  a  little  two-month  ovum  was 
expelled,  to  the  inexpressible  astonishment  of  the  parents  and 
the  chagrin  of  the  doctor. 

Miscarriage.— Much  that  has  been  said  of  abortion  is  ai)plic- 
able  to  miscarriage  as  well  ;  but  by  the  time  pregnane}-  has 
reached  a  period  from  the  fourth  to  the  seventh  month  it  is  not 

1  I  have  tried  every  model  of  a  two-way  uterine  catheter  on  the  market  and  find 
Fritsch's  modification  of  Bozeman's  the  best. 

2  The  fetus  has  been  retained  in  titero  five,  eleven,  and  even  fifty  one  years— 
L,  C.  Peter,  "Amer.  Gyn.  and  Oijstet.  Jour.,"  F>h.,  1899. 


284  PREGNANCY. 

likely  that  the  condition  will  be  overlooked,  so  that  one  great 
difficulty  in  the  diagnosis  of  abortion,  the  doubt  as  to  the  exist- 
ence of  pregnancy,  does  not,  as  a  rule,  obtain  in  cases  of  mis- 
carriage. In  these  cases,  too,  it  is  easier  to  detect  the  two  acci- 
dents which  make  the  expulsion  of  the  ovum  almost  inevitable — 
rupture  of  the  membranes  and  the  death  of  the  fetus  ;  for  the 
liquor  amnii  has  reached  such  a  quantity  that  its  escape  would 
almost  always  attract  attention,  while  the  death  of  the  fetus,  fol- 
lowed by  a  cessation  of  fetal  movements  and  of  growth  in  the 
uterus,  by  a  disappearance  of  the  reflex  and  psychical  disturb- 
ances characteristic  of  pregnancy,  and  also,  perhaps,  by  the  ap- 
pearance of  the  milk-secretion,  is  not  likely  to  pass  unnoticed. 
The  pain  associated  with  miscarriage  is  greater  than  in  abortion, 
and  assumes  the  type  of  labor-pains.  During  the  periodic  con- 
tractions of  the  uterus  the  organ  can  be  felt  through  the  abdom- 
inal walls,  becoming  hard  and  firm  and  relaxing  again  as  the 
pain  passes  off  The  expulsion  of  the  ovum  resembles  also  a 
labor  at  term,  as  the  fetus  usually  is  first  expelled  and  the  mem- 
branes and  placenta  follow  after.  As  pregnancy  advances  this 
sequence  becomes  more  and  more  the  rule,  but  occasionally  the 
ovum  is  cast  off  entire,  even  at  a  late  period  of  pregnancy.  I 
have  seen  such  an  occurrence  at  the  seventh  month,  and  it  has 
actually  been  reported  to  have  occurred  at  term. 

Miscarriage  is  chiefly  distinguished  from  abortion  by  the  for- 
mation of  the  placenta,  and  from  premature  labor  by  the  adhe- 
sion of  the  placenta  to  the  uterine  wall,  its  retention,  and  con- 
sequent serious  hemorrhage  or  infection. 

EXTRA=UTERINE   PREGNANCY. 

By  extra-uterine  or  ectopic  pregnancy  is  meant  the  develop- 
ment of  an  impregnated  ovum  outside  of  the  uterine  cavity.  The 
condition  was  described  by  Riolanus,  Benedict  Vassal  (1669), 
and  by  Regnier  de  Graaf  Abdominal  sections  for  extra-uterine 
pregnancies  were  performed  by  Nufer  (1500)  and  by  Dirlewang 
(1549).  Bohmer  (1752)  differentiated  the  tubal,  ovarian,  and 
abdominal  forms  of  ectopic  gestation.  Schmidt  (1801)  described 
interstitial  pregnancy. 

Frequency. — The  exact  proportion  of  extra-uterine  to  intra- 
uterine gestations  is  difficult  to  determine.  It  has  been  said  to 
be  about  i  in  500  normal  pregnancies.  Winckel,  however,  saw 
but  16  cases  in  22,000  births,  and  Bandl,  in  Vienna  but  3  out  of 
60,000.  An  experienced  speciahst  in  the  larger  cities  of  America 
usually  sees  from  three  to  fifteen  cases  annually. 


EXTKA-UTERINE  PREGNANCY.  285 

Classification  Based  upon  the  Situation  of  the  Developing 
Ovum. 

Tubal. 

Tubo-uterine,  or  interstitial.      The  ovum  develops  in  that 
portion  of  the  tube  which  runs  through  the  uterine  wall. 
Tubal  proper. 

Tubo-ovarian.      The  ovum  is  attached   to   the   ovarian   fim- 
bria. 
Ovarian.     The  ovum  develops  in  a  Graafian  follicle. 
Abdominal.     In  primary  abdominal  pregnancy  the  o\'um    im- 
beds itself  in  the  peritoneum. 
Secondary  abdovii)ial. 

Ovario-abdominal.      The  ovum,  beginning  its  growth  in  the 
ovary,  pushes  its  way  out  into  the  abdominal  cavity. 


Fig.  185. — Bifurcation  of  tubal  canal  (Henni 


Tubo-abdominal.  The  ovum,  at  first  contained  in  the  tube, 
escapes  into  the  abdominal  cavity  by  rupture  or  by  a 
gradual  separation  of  the  fibers  in  the  tubal  coat.  There 
is  a  form  of  tubal  pregnancy  often  called  secondary  ab- 
dominal or  tubo-abdomnial,  in  which  the  ovum  grows 
downward  and  backward  behind  the  peritoneum.  This 
should  be  known  as  a  broad-ligament  or  retroperitoneal 
pregnancy. 

Utero-abdominal.  The  ovum  grows  at  first  in  the  uterine 
cavity,  but,  in  consequence  of  a  spontaneous  rupture  or 
separation  of  an  old  scar  in  the  uterine  wall,  becomes  an 
abdominal  pregnancy,  retaining  its  connection  with  the 
uterus  by  the  placenta. 
Etiology. — ^The   causes   of    ectopic    gestation    arc    conditions 


PREGNANCY. 


delaying  the  progress  of  the  ovum  from  the  ovary  to  the  uterus 
until  a  stage  of  development  is  reached  at  which  the  ovum  imbeds 
itself  in  maternal  tissues.  Any  disease  of  the  mucous  membrane 
of  the  tube  depriving  its  cells  of  their  ciha,  forming  mucous  polypi 
or  otherwise  obstructing  its  caliber,  predisposes  to  an  arrest  of  the 
impregnated  ovum  in  its  passage  to  the  womb.  So  does  any 
condition  interfering  with  the  normal  peristalsis  of  the  tube. 
Chronic  salpingitis,  therefore,  is  often  found  associated  with  and 
preceding  tubal  pregnancy. 

Peritoneal  acUiesions  from  a  precedent  salpingitis  ^  or  appendi- 
citis constricting  or  distorting  the 
tubes  and  congenital  or  acquired 
stenosis  may  also  obstruct  the  tu- 
bal canals.  A  diverticulum  in  the 
tube,  an  accessory  tubal  canal, 
accessory  abdominal  ostia,  and 
atresia  of  the  tube  have  been 
noted  in  connection  with  ectopic 
gestation.  An  exaggeration  of  the 
characteristic  serpentine  course  of 
the  tube  may  make  the  progress  of 
the  ovum  difficult  and  may  arrest 
it  before  it  can  reach  the  uterus. 
Fibromyomata  of  the  uterus  and 
tumors  of  the  broad  ligament 
have  caused  tubal  obstruction. 
Anything  which  increases  the  size 
of  the  ovum  before  it  has  emerged 
from  the  tube  may  be  a  cause  of 
extrauterine  pregnancy;  thus,  ex- 
ternal transmigration,  twins,  or  an 
unusually  long  tube  may  result  in 
such  a  development  of  the  ovum  before  its  arrival  in  the  uterine 
cavity  that  it  imbeds  itself  in  the  tube. 

Clinical  History. — In  each  of  the  situations  noted  above  the 
course  of  gestation  may  be  somewhat  different,  and  each  may 
present  an  individual  clinical  picture  on  account  of  the  difference 
in  the  surrounding  anatomical  structures  which  are  involved. 
The  general  presumptive  signs  of  pregnancy  are  commonly  the 
same  as  in  intra-uterine  gestation,  but  there  is  usually  severe  pain. 


Fig.  l86. — Decidual  cast  of  the 
uterine  cavity  in  extra-uterine  preg- 
nancy (Zweifel). 


^  The  majority  of  my  cases  have  had  a  history  of  previous  salpingitis,  and  I  have 
treated  several  of  them  for  gonorrhea  months  and  years  before  the  tubal  gestation 
occurred.  In  one  case  I  found  a  four  weeks'  ovum  and  embryo  in  the  middle  of  a 
gonorrheal  pus  tube  that  had  been  under  observation  for  a  year.  The  operation 
was  performed  for  what  was  supposed  to  be  an  exacerbation  of  the  salpingitis. 


EXTRA-UTERINE  PREGNANCY.  287 

Extra-Uterine  pregnancy  occurs  oftenest  between  the  twentieth 
and  thirtieth  years.  The  youngest  woriian  affected  was  fourteen, 
the  oldest  fortv-seven  vears  of  age. 

Changes  in  Uterus  and  Vagina. — In  all  the  forms  these 
changes  are  alike.  Most  of  the  alterations  characteristic 
of  intra-uterine  pregnancy  are  found:  hypertrophy  of  the 
vaginal  mucous  membrane,  with  increased  blood-supply  (purple 
tinge)  and  increased  secretion  ;  a  soft  cervix  and  a  patulous  os  ; 
an  enlarged  uterus,  and,  in  the  majority  of  cases,  a  development 
of  a  deciduous  membrane,  undergoing  the  same  change  as  in  intra- 
uterine gestation  preparatory  to  its  separation  and  extrusion,  which 
occurs  in  extra-uterine  gestation  usually  between  the  eighth  and 
twelfth  week,  the  membrane  being  expelled  as  a  complete  cast  of 
the  uterus  and  even  of  the  tubes,  or  in  shreds.  The  usual  clinical 
history  of  ectopic  gestation  is  absence  of  menstruation  until  the 
death  of  the  embryo  or  rupture  of  the  sac,  when  the  menses  return 
with  the  discharge  of  the  decidua.  The  metrorrhagia  which  thus 
begins  may  continue  for  a  long  time. 

The  other  changes  in  the  maternal  organism  may  vary  with 
the  situation  of  the  developing  ovum. 

Clinical  History  and  Pathology  of  Tubal  Pregnancy. — 
Usually  the  woman  has  had  children,  but  a  long  time  has 
elapsed  since  the  birth  of  the  last  child.  The  most  frequent 
situation  of  an  extra-uterine  gestation  is  the  outer  third  of  the 
tube  (the  ampulla  i).  In  this  position  it  may  grow  upward  into 
the  abdominal  cavity,  distending  the  tube -walls  to  the  point  of 
rupture,  or  it  may  grow  downward  between  the  layers  of  the  broad 
ligament,  and  then  backward  and  upward  behind  the  posterior 
parietal  layer  of  the  peritoneum  (broad-ligament  gestation). 
The  tubal  walls  show  irregular  hypertrophy  from  the  development 
of  their  muscle-fibers.  The  point  of  rupture  is  at  the  site  of 
original  attachment  of  the  ovum,  the  cells  of  the  chorion  villi 
burrowing  into  the  tubal  wall  and  weakening  it.  Fever  is  often 
seen,  sometimes  to  a  high  degree,  even  before  rupture.  The  usual 
temperature,  however,  before  rupture  is  between  99°  and  100°  F. 
After  rupture  there  may  be  a  low  temperature  indicative  of  hemor- 
rhage. Reaction  may  quickly  occur,  and  fever  is  not  incom- 
patible with  profuse  intraperitoneal  hemorrhage.  There  is  a 
moderate  leukocytosis,  usually  about  12,000.  Exceptionally, 
the  tubal  gestation  may  proceed  to  full  term.  In  these  cases 
the  ovule  has  probably  at  first  grown  downward  and  backward. 
If  perforation  of  the  tubal  wall  occurs,  it  usually  takes  place 
between  the  eighth  and  twelfth  weeks,  but  it  may  occur  as  early  as 

1  Martin's  statistics  of  55  cases  of  cxtra-uteiine  pregnancy  give  this  situation 
in  49. 


288  PREGNANCY.  ■ 

the  fourteenth  day/  or  not  till  after  the  sixth  month.  If  the  tube 
ruptures  upon  the  upper  or  posterior  aspect  of  the  sac,  the  sac-con- 
tents are  extruded  into  the  peritoneal  cavity  with  an  intra-peritoneal 
hemorrhage.  If  rupture  occurs  on  the  lower  aspect,  the  con- 
tents of  the  ovum  and  the  blood  find  their  way  between  the 
layers  of  the  broad  ligament  and  the  pelvic  fascia,  giving  rise  to 
an  extraperitoneal  hematocele.  The  first  variety  is  usually  fatal ; 
the  last  is  not  always  directly  dangerous  to  hfe,  but  the  layers 
of  the  broad  ligament  may  rupture  when  distended  with  blood, 
and  the  bleeding  then  becomes  intraperitoneal  and  unlimited. 
The  bleeding  may  also  be  limited  by  peritoneal  adhesions  shut- 


Fig.  187. — Broad  ligament  pregnancy  (Zweifel). 

ting  off  the  peritoneal  cavity  and  forming  a  closed  sac  in  the 
\\\Sc  region.  From  adhesions  to  intestines,  complications,  such 
as  perforation  and  obstruction  of  the  bowel,  may  occur. 

Recent  studies  of  the  behavior  of  the  ovum  in  relation  with  the 
tubal  wall  and  the  mucous  membrane  explain  the  difference  of 
opinion  once  prevalent  as  to  decidua  formation  and  also  explam 
the  clinical  course  of  tubal  gestation.  The  ovum  may  imbed  itself 
either  in  pKcations  of  the  tubal  mucous  membrane  or  directly  m 
the  muscular  tubal  wall.  In  the  former  case  the  bed  of  the  ovum 
is  in  the  connective  tissue  of  a  stem  of  the  mucous  membrane 
folds.  The  maternal  tissues,  including  blood-vessels,  are  eroded 
by  the  cells  of  the  trophoblast;  the  thin  capsule  of  the  ovum  is 
penetrated  and,  hemorrhage  occurring  into  the  lumen  of  the  tube, 

1  Ross,  ' '  Am.  Tour.  Obstet.,"  October,  1895.  According  to  Hacker's  statistics 
of  45  cases,  rupture  occurred  26  times  in  the  first  two  months,  11  tmies  m  the  third, 
7  in  the  fourth,  and  once  in  the  fifth.  In  two  of  my  cases  rupture  occurred  no  later 
than  the  fourteenth  day. 


EXTRA-UTERINE  PREGNANCY. 


289 


Fig.  188. — A  ruptured  broad  ligament  pregnancy. 


Fig.   189 — Ruptured  broad  ligament  pregnancy. 


Fig.  190 — Ruptured  broad  ligament  pregnancy.      The  embryo  ///  situ 
19 


290 


PREGNANCY. 


escapes  from  the  fimbriated  extremity  into  the  peritoneal  cavity 
(tubal  abortion).  In  the  latter  case  the  trophoblast  makes  a 
nest  for  the  ovum  in  the  tubal  wall,  burrowing  into  the  muscle  at 
the  base  of  the  plications  of  the  mucous  membrane  or  in  the 
isthmus  where  these  plications  are  not  developed.  At  the  point 
where  the  ovum  attaches  itself  the  cells  of  the  vilh  penetrate  toward 
the  periphery  of  the  tube,  opening  the  walls  of  blood-vessels  and 
penetrating  the  tubal  wall  to  the  serous  covering,  which  eventually 
gives  way.  Thus  the  so-called  rupture  of  tubal  pregnancies 
occurs,  with  intraperitoneal  hemorrhage. 


6- 


d- 


Fig.  191, — Interstitial  pregnancy,  fourth  month  ;  vaginal  hysterectomy,  a,  Cav- 
ity of  the  ovum;  b,  uterine  cavity;  £-,  left  tube;  (/,  cervix;  e,  partially  detached 
placenta;  /,  right  tube;  g,  right  ovary  (Bumm). 


There  can  be  no  true  decidual  formation  in  the  nest  which 
the  ovum  makes  for  itself  in  muscular  tissue,  beneath  the  tubal 
mucous  membrane,  for  the  cells  of  the  intermuscular  connective 
tissue  do  not  undergo  this  metaplasia,  but  in  other  portions  of  the 
tubal  mucous  membrane  distant  from  the  o\aim,  even  in  the  other 
tube,  there  is  an  irregular  development  in  limited  areas  of  decidual 
cells.  The  cells  in  the  bed  of  the  oAoim,  often  described  as  decid- 
ual cells,  are  really  derived  from  the  trophoblast  (Langhans' 
cells).     There  may  be  a  reflexa  formation,  irregularly  and  feebly 


EXTRA-UTERINE  PREGNANCY.  29I 

developed  as  the  ovum  grows  and  projects  into  the  lumen  of  the 
tube,  but  there  is  often  an  underlying  layer  of  muscular  tissue  and 
the  capsule  of  the  ovum  soon  degenerates  and  is  penetrated  by 
the  trophoblast,  so  that  the  villi  of  the  latter  contract  attachments 
with  the  plications  of  the  tubal  mucous  membrane  or,  in  the 
isthmus,  with  the  opposite  tubal  wall. 

There  may  be  multiple  (twin  and  triplet  ^)  extra-uterine  gesta- 
tion; coincident  intra-  and  extra-uterine  pregnancy;  pregnancy 
first  in  one  tube  and  then  in  the  other;  sim.ultaneous  pregnancies 
in  both  tubes  ^;  or  two  successive  pregnancies  in  the  same  tube.^ 
Hydramnios  was  noted  in  one  case  of  tubal  pregnancy  ^  and  a 
thoracopagus  was  found  in  another.^  Several  cases  of  hydatidi- 
form  mole  and  also  cases  of  chorio-epithelioma  have  been  observed 
in  tubal  pregnancies.® 

Clinical  History  of  Interstitial  Pregnancy. — The  ovum 
develops  in  the  uterine  wall,  the  inner  side  of  the  sac  often  pro- 
jecting into  the  uterine  cavity,  and  having  on  its  outer  side  the 
round  ligament  and  the  whole  length  of  the  tube.  The  usual 
termination  is  rupture  into  the  peritoneal  cavity.  Hecker  collected 
twenty-six  cases,  all  ending  in  rupture  before  the  sixth  month. 
Rupture  into  the  uterine  cavity  and  expulsion  of  the  fetus  through 
the  cervix  are  possible.  Rupture  into  or  growth  between  the  layers 
of  the  broad  ligament  is  also  possible.'^ 

Clinical  History  of  Tubo=ovarian  Pregnancy. — The  ovum 
develops  between  the  fimbriae  of  the  tube  and  the  ovary.  The  sac 
may  rupture  with  the  usual  consequences  of  such  accident.  It  is 
possible,  however,  to  see  a  development  of  the  fetus  to  maturity. 
The  ovum  may  lodge  upon  the  ovarian  fimbria  and  may  thence 
grow  inward  between  the  layers  of  the  broad  ligament. 

1  Sanger,  "  Centralbl.  f.  Gyn.,"  No.  7,  1893.  Krusen,  "  Tr.  Phila.  Co.  Med. 
See,"  October,  1901.  v.  Neugebauer,  "  Zur  Lehre  von  der  Zwilling  Schwanger- 
schaft  mit  heterogenem  Sitz  der  Friichte,"  Leipzic,  1907. 

'■'Martin  has  collected  8  cases,  "  Zeitschr.  f.  Geburtsh.  u.  Gyn.,"  Bd.  xxxviii, 
H.  I.     Jayle,  28  cases.     "  Rev.  de  Gyn.  et  de  Chir.  Abdom. ,"  No.  2,  1904. 

^  Coe,  "  N.  Y.  Med.  Record,"  May  27,  1893;  Borland,  "Repeated  Extra- 
uterine Pregnancy,"  "Amer.  Jour.  Obstetrics,"  April,  1898;  Royster,  "Combined 
Intra-  and  Extra-uterine  Pregnancy  at  Term,"  ibid.,  1897,  vol.  xxxvi,  p.  820; 
Mosely,  ibid.,  1896,  thirty-eight  cases  of  intra-  and  extra-uterine  pregnancy.  Zinke, 
ibid.,  xlv,  No.  5,  I902,  88  cases.  Neugebauer,  129  cases.  Heinricius  and  Kolster 
report  two  fully  developed  fetuses  in  one  tube,  one  macerated,  the  other  well  pre- 
served, "Archiv  f.  Gyn.,"  Bd.  Iviii.  Pestalozza  has  collected  108  cases  of  repeated 
tubal  pregnancies:  "Arch.  Ital.  di  Gin.,"  No.  5,  p.  474,  1900.     Naples. 

^  "Archiv  f.  Gyn.,"  Bd.  xxii,  S.  57. 

5  "Centralbl.  f.  Gyn.,"  1894,  p.  232. 

»  Werth,  "Winckel's  Handbuch,"  2^,  p.  822. 

'  Werth  gives  forty  as  the  number  of  interstitial  pregnancies  in  the  literature 
which  bear  criticism.     "  Winckel's  Handbuch,"  2^,  p.  739. 


292  PREGNANCY. 

Clinical  History  of  Ovarian  Pregnancy. — The  ovum,  im- 
pregnated while  it  is  still  within  the  Graafian  follicle,  reaches 
some  degree  of  growth  and  development  within  the  ovary.  The 
tube  and  ovarian  fimbria  are  free,  the  uterus  is  connected  by  the 
ovarian  ligament  with  the  gestation  sac,  the  wall  of  which  consists 
in  great  part  at  least  of  ovarian  tissue.  The  condition  is  exceed- 
ingly rare,  but  there  are  a  few  indubitable  cases  on  record.^  A 
case  reported  by  Baer  went  to  term.  Miiller  and  Widerstein  have 
reported  cases  of  the  prolapse  of  a  pregnant  ovary  into  the  inguinal 
ring  and  canal. 

Clinical  History  of  Abdominal  Pregnancy.— Primary  ab- 
dominal pregnancy  is  exceedingly  rare.  Many  gynecologists 
deny  its  occurrence,  but  there  have  been  a  few  authentic  cases.^ 
The  conditions  in  the  free  abdominal  cavity  favor  the  progress  of 
pregnancy  to  the  mature  development  of  fetus.  The  peritoneum  is 
converted  into  decidua-like  membrane  wherever  the  ovum  comes 
in  contact  with  it,  and  from  this  source  the  chorion  and  placenta 
derive  nutriment.  The  ovum  is  surrounded  by  a  fibrous  and  vas- 
cular capsule.  In  abdominal  and  in  advanced  tubal  gestation 
abortive  labor-pains  appear  at  term.  The  child  dies  at  or  shortly 
after  this  period,  and  the  liquor  amnii  is  absorbed  after  the  death 
of  the  fetus.  Tlie  abdomen  is  consequently  reduced  in  size  and 
the  tumor  is  ciranged  in  consistency.  The  fetus  may  be  con- 
verted into  a  lithopedion  and  may  remain  as  an  innocuous  tumor 
in  the  abdomen  for  years  (see  Termination  of  Extra-uterine 
Pregnancy,  and  Changes  in  Fetal  Body  after  Death).  The  child 
is  likely  to  be  small  and  ill-formed,  but  occasionally  over- 
grown children  are  reported,  if  fetal  life  is  prolonged  beyond  the 
usual  duration  of  pregnancy.  In  advanced  cases  of  abdominal 
pregnancy  the  fetal  movements  are  exceedingly  painful  to  the 

^  Cases  are  reported  by  Potenko,  Werth,  Paltauf,  Leopold,  and  Martin.  See 
Winckel,  "  Geburtshiilfe " ;  Kelly,  article  in  "American  Text-book  of  Obstetrics.'' 
Ludwig,  "  Wien.  klin.  Woch. ,"  1896,  has  collected  18  cases  besides  one  of  his 
own.  Leopold  claims  that  there  are  thirteen  authentic  cases  recorded,  "  Archiv  i. 
Gyn. ,"  Bd.  lix.  Catharine  von  Tussenbroek  demonstrated  a  specimen  removed  by 
Kouwer,  of  Harlem,  "  Tr.  Ill  Congress  of  Gyn.  and  Obst.,"  Amsterdam,  1899. 
Micholitsch  found  two  cases  among  120  cases  of  extra-uterine  pregnancy  operated  on 
in  Wertheim's  Clinic  ( "  Zeitschr.  f.  Geb.  u.  Gyn.,'-'  Bd.  xlix,  H.  3).  C.  C.  Norris, 
"Tr.  Philada.  Obstet.  Soc. ,"  1908;  Bryce,  Teacher  and  Kerr,  "Early  Ovarian 
Pregnancy,"  Glasgow,  1908. 

^  Schlechtendahl  has  reported  a  case  of  primary  abdominal  pregnancy  in  which 
a  fetus  fifteen  centimeters  long  was  found  incapsulated  near  the  spleen.  The  tubes 
and  uterus  were  normal  ('•  Frauenarzt,"  18S7,  ii,  pp.  81-86).  Braun's  and  Zweifel's 
cases  ("Archiv  f.  Gyn.,"  Bd.  xli,  H.  i  and  2),  in  which  the  placenta  was  attached 
to  the  posterior  uterine  wall  and  to  the  sigmoid  flexure,  and  Koberle's  case,  in  which 
impregnation  occurred  through  a  vagino-abdominal  fistula  after  hysterectomy,  were 
probably  primary  abdominal  pregnancies.  Three  cases  may  be  accepted  as  beyond 
criticism:  Galabin's,  Witthauer's,  and  the  author's.  (Hirst  and  Knipe,  "Surgery, 
Gyn.  and  Obstet.,"  October,  1908.) 


EXTRA-  UTERINE   PRE  GNANC  V. 


293 


mother.     Abdominal  pregnancies  may  end  in  rupture  of  the  sac 
or  there  may  be  profuse  hemorrhage  into  the  sac-cavity. 


*<« 


Fig.    192. — Tubo-ovarian  pregnancy.      Sac  ruptured. 


Fig.  193. — The  ovum  imbedded  under  the  peritoneum  of  the  broad  ligament. 


Clinical  History  and  Pathology  of  Utero=abdominal  Preg= 
nancy. — This  condition  is  very  rare.  The  pregnancy  is  at  first 
intra-uterine,  but  the  o\'um  escapes  into  the  abdominal  cavity 
through  an  opening  in  the  uterine  ^vall,  retaining  a  connection 
by  the  placenta  with  the  uterine  cavity.  The  process  of  extru- 
sion must  be  gradual.     These  cases  follow   either    a  Cesarean 


294 


PREGNANCY. 


Fig.    194. — Reported  as  an  ovarian  pregnancy. 


Fig.   195. — Reported  as  an 
ovarian  pregnancy. 


Fig.  196. — August  Martin's  case  of  ovarian  pregnancy.  Tlie  intact  tube  is 
seen  lying  above  the  ovarian  sac  containing  the  fetal  envelopes.  The  ovarian  liga- 
ment runs  from  the  sac  to  the  uterine  cornu. 


EXTRA-UTERINE   PREGNANCY. 


295 


section  or  a  rupture  of  the  uterus  at  a  previous  labor.  The 
fetus  may  grow  to  full  term.  ^ 

Terminations  of  Extra=uterine  Pregnancy. — Death  and  Ab- 
sorption of  the  ] \ving-  Embryo  zvitJi  Absorption  of  the  Liquor  Amnii, 
and  Atrophy  of  the  Gestation  Cyst. — Of  all  the  terminations  of 
ectopic  gestation,  this  is  the  most  favorable.  It  is  exceptional, 
and  should  never  be  counted  on  in  practice.  The  embryo  must 
die  before  the  second  month  to  be  completely  absorbed.  At  the 
best,  chronic  salpingitis  with  adhesions  persists,  and  the  woman 
may,  therefore,  be  left  a  chronic  invalid. 

Rupture  of  the  sac  and  profuse  hemorrhage  occur  most  com- 
monly in  tubal  gestation,  when  the  growth  is  upward  toward  the 
abdominal  cavity.  At  least  two-thirds  of  all  ectopic  gestations 
end  in  rupture  of  the  sac  or  in  tubal  abortion.     Rupture  may 


0^<^*^ 


Fig.  197- — Ruptured  tubal  pregnancy  ;  sac  involving  the  isthmus. - 

occur  when  the  ovule  grows  downward  between  the  layers  of  the 
broad  ligament;  also  in  tubo-uterine,  tubo-ovarian,  ovarian,  and 
abdominal  pregnancies.  The  accident  commonly  destroys  the 
embryo,  which  may  escape  into  the  abdominal  cavity.  Up  to  the 
second  month  the  extruded  embryo  may  be  absorbed.  Later,  it 
may  be  found  lodged  among  the  intestines,  perhaps  far  removed 
from  the  pelvic  organs  and  usually  surrounded  by  clotted  blood.^ 

'  "  Ausgetragene  secundare  Abdominalschwangerschaft  nach  Ruptura  uteri,  im 
vierten  Monat,"  Leopold,  "  Archiv  f.  Gyn./'  lii,  2,  376.  Fullerton,  "  Annals  of 
Gyn.,"  October,  1891. 

'■Tigs.  188  to  190  and  197  to  206  inclusive,  also  figs.  192  to  195,  are  from 
photographs  presented  to  me  by  the  late  Ur.  Formad,  for  some  time  coroner's 
physician  of  Philadelphia.  He  obtained  the  sjiecimens  in  his  official  capacity, 
while  investigating  the  cause  of  sudden  deaths. 

3  Burford  reports  an  extraordinary  case  in  which  the  tube  ruptured,  the  fetus  was 
extruded  through  the  rent,  the  cord  was  torn  across,  and  the  fetus  with  the  cord 
attached  was  found  in  the  abdominal  cavity  inclosed  in  an  adventitious  sac.  The 
placenta  remained  in  the  tube  and  the  rent  in  the  latter,  through  which  the  fetus 
escaped,  had  healed.     "  Brit.  Gyn.  Jour.,"  1892. 


296  PREGNANCY.    ' 

Rupture  of  the  tubal  wall  has  been  reported  without  hemorrhage, 
the  head  of  the  embryo  fitting  into  the  gap  and  acting  as  a  tam- 
pon. The  hemorrhage  may  be  fatal  in  as  short  a  time  as  two 
hours;  it  usually  takes  from  eight  to  sixteen  hours,  however,  for 
the  woman  to  bleed  to  death.  The  hemorrhage  may  be  fatal  as 
late  as  the  second,  third,  or  fourth  day,  or  there  may  be  succes- 
sive hemorrhages,  perhaps  days  apart,  until  the  patient  is  grad- 
ually exhausted  or  is  suddenly  destroyed  by  an  unusually  profuse 
outpour  of  blood.  Surprisingly  small  tubal  gestation  sacs  may, 
on  rupture,  give  rise  to  fatal  hemorrhage.  In  such  cases  the 
ovum  is  usually  imbedded  in  the  tube  near  the  cornu  of  the 
uterus.  The  determining  cause  of  rupture  is  not  always  apparent. 
It  may  occur  while  the  patient  is  lying  quietly  in  bed,  but  may 
follow  the  straining  of  defecation  or  urination,  coitus,  a  blov/  upon 
the  abdomen,  a  gynecological  examination,  an  operation  like  curet- 
ment,  or  any  sudden  physical  effort  or  mental  excitement.  The 
trophoblast  having  eroded  the  tubal  wall  to  and  even  through  the 
peritoneum,  it  requires  little  or  no  extra  strain  to  establish  a  com- 


Fig.  198. — Ruptured  tubal  pregnancy ;  sac  involving  the  whole  length  of  the  tube. 

munication  between  the  bed  of  the  ovum,  with  its  opened  blood- 
vessels, and  the  peritoneal  cavity.  Rupture  of  the  sac  or  of  a 
blood-vessel  in  its  wall,  with  profuse  hemorrhage,  has  occurred 
long  after  the  destruction  of  the  embryo  and  cessation  of  growth 
in  the  sac  (two  years  in  one  case). 

Rupture  of  sac  with  extrusion  of  its  contents,  and  interstitial 
hemorrhage  into  the  sac-walls,  without  escape  of  blood  into  peri- 
toneal cavity  or  between  the  layers  of  broad  ligament,  was  the 
termination  of  one  case  of  tubal  gestation  under  my  observation. 


EXTRA-  UTERINE   PRE GNANC Y. 


297 


Fig.    199. — Ruptured  tubal  pregnancy ;   sac  involving  the  ampulla. 


Fig.  200. — Ruptured  tubal  pregnancy  ;  sac  situated  wholly  in  the  isthmus.  The 
size  of  the  sac  is  very  small  to  occasion,  on  rupture,  a  fatal  hemorrhage;  its  situation, 
however,  near  the  uterus,  is  a  very  dangerous  one.  The  decidua  lining  the  uterine 
cavity  is  plainly  seen. 


^5h[Wj^- 


Fig.  201. — Ruptured  tubal  pregnancy;   sac  occupying  the  middle  third  of  the  tube. 


298 


PREGNANCY. 


Fig.  202. — A  very  small  gestation  sac  in  middle  third  of  tube. 
Rupture ;   death. 


•  ^te^f" 


-iS^ 


Fig.  203.  —  Ruptured  tubal  pregnancy  ;  the  sac  occupying  the  ampulla  and  fimbriated 
extremity  of  the  tube. 


Fig.  204. — Ruptured  tubal  pregnancy  ;   the  sac  situated  at  the  uterine  insertion 

of  the  tube. 


EXTRA-UTERINE   PREGNANCY.  299 

This  occurrence  might  be  followed  by  atrophy  of  the  ovum  and 
sac. 

Tiibal  moles  are  frequently  seen  as  the  result  of  an  old  tubal 
pregnancy ;  the  ovum  is  infiltrated  and  surrounded  by  blood, 
clotted  and  often  organized.  The  tubal  walls  are  also  infiltrated 
with  blood  and  are  much  thickened.  The  whole  mass  constitutes 
a  solid  tumor  of  the  tube  in  which  the  embryo  may  not  be  found, 
and  atrophied  chorion  villi  in  small  numbers  are  only  discovered 
after  a  careful  microscopic  search, 

Growtli  of  the  Fetus  after  Third  Month  ;  Its  Death  at  or  before 
Matiirity  and  the  Changes  that  Occur  Afterivard. — A  continued  de- 
velopment of  the  fetus  in  the  later  months  of  pregnancy  is 
seen  most  often  in  abdominal  or  in  tubo-ovarian  pregnancies, 
though  it  is  possible  in  the  tubal  gestation  with  retroperitoneal 
growth  (broad-ligament  pregnancy).  The  fetus  after  death 
may  be  converted  into  a  lithopedion  or  may  be  mummified,  and 
in  these  conditions  may  remain  in  the  abdominal  cavity  indefi- 
nitely (in  Sappey's  case  fifty-six  years),  or  may  be  removed  by 
operation  through  the  abdomen,  vaginal  vault,  or  possibly  by 
the  rectum.  The  soft  parts  may  macerate  and  may  be  absorbed, 
leaving  the  bones,  which  remain  as  an  innocuous  abdominal 
tumor  or  ulcerate  into  the  bladder,  intestines,  or  through  the 
anterior  abdominal  wall.  Ulceration  into  the  bladder  is  a  par- 
ticularly unfortunate  complication.  I  have  seen  an  old  lady  die 
of  peritonitis  caused  by  the  ulceration  of  a  parietal  bone  through 
the  transverse  colon.  Her  history  indicated  an  abdominal  preg- 
nancy many  years  before. 

The  fetal  body  may  putrefy  from  the  contiguity  of  the  intes- 
tines and  their  contained  micro-organisms  and  the  consequent 
access  of  bacteria  to  the  highly  putrescible  sac-contents.  In  the 
same  way  the  gestation-sac  is  converted  into  an  abscess. 

Termiiiations  of  Ovarian  Pregnancy. — There  may  be  an  arrest 
in  the  development  of  the  ovum  at  an  early  period.  In  one 
case  the  small,  cystic,  ovarian  tumor  containing  the  fetal  bones 
was  retained  in  the  abdomen  for  years.  In  another  case  the 
fetus  went  on  to  full  development,  then  died,  and  was  removed 
in  a  good  state  of  preservation  at  least  one  year  later.  Rupture 
of  the  sac  and  profuse  hemorrhage  may  occur. 

In  tubo- uterine  or  interstitial  pregnancies  the  ovum  and  em- 
bryo may  be  discharged  into  the  uterine  cavity,  and  may  be 
evacuated  by  the  natural  pa.ssagcs.  There  are  at  least  two  such 
cases  well  authenticated.  Rupture  of  the  sac  and  hemorrhage 
into  the  peritoneal  cavity  is,  however,  the  rule.  In  Mascka's 
case  the  head  of  the  fetus  passed  into  the  abdominal,  the  breech 
into  the  uterine,  cavitv. 


300 


PREGNANCY. 


In  cases  of  hihal  abortion  (so  named  by  Werth)  there  is 
an  internal  rupture  of  the  tubal  wall,  of  its  connection  with  the 
ovum,  or  the  epithelial  cells  of  the  chorion  villi  penetrate  the 
wall  of  a  vessel  of  some  size,  and  blood  is  poured  through  the 
fimbriated  extremity  of  the  tube  into  the  abdominal  cavity.     The 


Fig.  205. — Tubal  abortion. 


Fig.   206. — Tubal  abortion. 

blood-clots  filling  the  pelvis  in  such  a  case  may  have  a  peculiar 
sausage-like  form  imparted  to  them  by  the  tubal  canal.  The  whole 
ovum  may  possibly  be  extruded  through  the  abdominal  orifice  of 
the  tube,  and  in  one  case  in  which  the  fimbriated  extremity  was 
closed  by  inflammatory  adhesions  the  outer  end  of  the  tube  was 
converted    into    a   hematoma.     Tubal    abortion    is    much    more 


EXTRA- UTERINE   PREGNANCY. 


301 


frequent  than  rupture.     In  75  cases  the  former  occurred  59,  the 
latter  16,  times.^ 

It  is  possible  that  a  tubal  pregnancy  may  rupture  in  its  early 
stages,  the  embryo  be  expelled  into  the  abdominal  cavity,  retain- 


Fig.  207. — Tubal  abortion  and  extruded  mole. 


Bladder 


Fig.  208. — Diagram  showing  pelvic  hematocele  posterior  to  tlie  uterus,  which 
is  crowded  forward  with  the  bladder  behind  the  symphysis  pubis,  while  the  rectum 
is  compressed  behind  against  the  sacrum  (Skene). 

ing  its  connection  with  the  tul)e  by  the  cord  and  ])lacenta,  and 
the  fetus  thus  continue  to  further  or  to  full  develojMncnt.  This 
is  called  a  secondary  or  tuho-ahdominal  pregnancy.-     Rupture  in 

1  "  Volkmann's  Samml.  khn.  Vortrage,"  N.  F.,  Nos.  244,  245. 
'^  Lusk  has  collected  tliree  such  cases.     The  fetus  survived  tlie  rupture  of  the  tube, 
or  the  extrusion  may  have  been  gradual  by  a  separation  of  the  fibers  in  the  tube  wall. 


302 


PREGNANCY. 


cases  apparently  of  this  character  may  not  have  occurred.  There 
may  have  been  a  retroperitoneal  growth  of  the  ovum  and  an 
enormous  dilatation  of  the  tubal  walls. 

Growth  and  development  of  the  placenta  after  fetal  death  has 
been  described,  but  has  not  yet  been  demonstrated  beyond  doubt. 
It  would  seem  impossible,  arguing  from  the  behavior  of  the 
placenta  in  utero  after  fetal  death. 

Profuse  hemorrhage  into  the  gestation  sac,  forming  a  large 
hematoma,  occurred  in  one  case  under  my  observation. 


Fig.  209. — Diagram  of  intraperitoneal  rupture  of  tubal  pregnancy.  Free  blood 
in  Douglas'  cul-de-sac,  and  among  the  intestines:  S,  Symphysis;  R,  rectum 
(Dickinson). 

Hematoceles  and  hematomata  in  the  abdomen,  pelvis,  and  pelvic 
comiective  tissue  in  one-third  or  more  of  the  cases  are  due  to  the 
hemorrhage  from  a  ruptured  gestation  sac.  The  blood  may 
collect  in  front  of  the  uterus  (ante-uterine  hematocele),  more 
commonly  behind  the  uterus  (retro-uterine  hematocele),  may  be 
encapsulated  in  the  neighborhood  of  either  broad  ligament,  or 
may  be  contained  in  the  pelvic  connective  tissue  on  either  side 
of  the  uterus.  These  accumulations  of  blood  may  suppurate, 
and  may  thus  prove  fatal.  They  may  be  evacuated  by  puncture 
through  the  abdomen  or  often  through  the  vaginal  vault.  If  not 
too  large,  they  are  absorbed. 


EXTRA- UTERINE  PREGNANCY.  303 

Symptoms  of  Extra=uterine  Gestation. — The  Subjective 
Signs. — In  the  early  weeks  or  months  the  subjective  signs  of 
ectopic  pregnancy  may  be  indistinguishable  from,  those  of  normal 
intra-uterine  gestation.  In  the  tubal  variety,  which  is  by  far  the 
commonest,  there  may  be  no  indication  of  any  abnormality 
until  rupture  occurs  or  blood  escapes  into  the  peritoneal  cavity 
from  the  fimbriated  extremity  of  the  tube.  In  the  vast  majority 
of  cases,  however,  rupture  or  bleeding  is  preceded  by  severe  cramp- 
hke  pains,  usually  in  one  or  the  other  iliac  region,  often  accom- 
panied or  followed  by  the  discharge  of  deciduous  membrane. 

The  pain  of  extra-uterine  pregnancy  is  its  most  distinctive 
symptom.  It  is  described  by  the  patient  in  strongest  terms;  oc- 
curring in  paroxysms,  with  intervals  free  from  suffering;  appear- 
ing at  any  time  from  a  few  days  to  months  after  a  normal  menstrua- 
tion; situated  often  in  one  groin,  though  frequently  indefinitely 
referred  to  the  lower  abdomen;  extending  down  one  leg  or  up  to 
the  epigastrium;  and  so  severe  as  to  occasion  profound  systemic 
disturbance — syncope,  followed  by  nausea  and  vomiting,  a  cold 
sweat,  hysterical  outbreaks,  complete  disabihty,  and  every  ap- 
pearance of  excessive  shock.  The  temperature  is  almost  always 
slightly  elevated.  The  pulse  is  rapid  and  the  blood-pressure  low 
if  there  has  been  much  hemorrhage.  In  one  case  extreme  brady- 
cardia was  reported,  probably  due  to  some  indirect  stimulus  of  the 
vagus.  There  may  be  high  fever  and  the  general  health  may  be 
much  impaired.  When  advanced  development  occurs,  as  in  ab- 
dominal and  in  some  cases  of  tubal  gestation,  no  symptoms  may 
arise  until  the  time  for  labor  has  passed,  when  pain  and  other 
compHcations,  due  to  the  peculiar  character  of  the  abdominal 
tumor,  may  appear.  There  is  usually  cessation  of  the  menstruation 
for  one  or  two  periods;  then  a  return  of  the  flow  as  an  irregular 
bleeding,  which  may  last  for  months.  In  some  cases  irregular 
bleedings  begin  with  conception  and  last  until  rupture — there 
is  no  cessation  of  menstruation.  In  others  one  period  is  slightly 
delayed;  those  after  and  before  are  normal.  Again,  the  delayed 
period  may  be  unnatural  in  character.  In  exceptional  cases 
the  menstruation  occurs  at  the  normal  time,  but  is  more  pro- 
fuse or  scantier  than  normal.  In  no  cases  upon  which  I  have 
operated  there  was  no  absence  of  menstruation  in  i8;  a  cessation 
of  menstruation  varying  from  10  to  90  days  in  92.  There  was 
metrorrhagia  lasting  from  2  to  120  days  in  92  cases;  there  was 
a  discharge  of  decidua  in  50  cases. 

Other  symptoms  noted  have  been  irritable  bladder  or  dys- 
uria;  marked  constipation  or  even  obstruction  of  the  bowels  if 
the  tumor  is  on  the  left  side;  edema  of  the  corresponding  limb 


304  PREGNANCY. 

and  aching  pain  in  it,  especially  at  the  groin  ;  or  numbness  and 
loss  of  power.     Pulsating  vessels  may  be  felt  in  the  vaginal  vault.  ^ 

Objective  Signs. — In  tubal  pregnancies  an  exquisitely  sensi- 
tive tumor  may  be  felt  to  one  side  of,  behind,  or  possibly  in  front, 
of  the  uterus,  quite  firmly  fixed  after  the  third  or  fourth  week, 
and  doughy  in  consistence.  ^  The  uterus  is  much  smaller  than 
would  be  expected  from  the  duration  of  the  pregnancy.  After 
the  third  month  ballottement  may  possibly  be  practised  upon 
the  tubal  tumor.  The  uterus  is  usually  displaced  forward, 
backward,  or  to  the  side  opposite  the  tumor.  The  decidua  is 
expelled  from  the  uterus  in  a  large  proportion  of  cases  (45  per 
cent,  of  my  own).  If  the  discharged  membrane  can  be  obtained, 
it  will  present,  under  the  microscope,  unmistakable  character- 
istics of  decidua.  It  may  be  extruded  in  fragments  or  as  a  com- 
plete cast  of  the  uterus. 

Symptoms  of  Interstitial  Pregnancy. — A  diagnosis  is  diffi- 
cult or  impossible.  The .  uterus  enlarges  to  a  greater  degree 
than  in  any  other  variety  of  ectopic  gestation,  and  it  may  be  im- 
possible to  determine  whether  or  not  it  is  symmetrically  enlarged. 
The  condition  is  recognized  after  an  abdominal  section  or  upon  a 
careful  intra-uterine  exploration.  ° 

Abdominal  pregnancy  may  be  recognized  when  the  ovum 
occupies  Douglas'  pouch,  as  the  fetal  parts  may  be  made  out 
with  startling  distinctness  through  the  posterior  vaginal  vault. 
A  sacculated  uterus,  however,  might  easily  be  mistaken  for  an 
abdominal  pregnancy.  There  is  unusual  pain  from  fetal  m_ove- 
ments,  and  abdominal  palpation  may  give  unusually  distinct 
results.     It  may  be  possible  to  outline  the  empty  uterus. 

Diagnosis. — A  diagnosis  of  extra-uterine  pregnancy  can 
usually  be  made  before  rupture.  In  spite,  however,  of  careful 
attention  to  the  patient's  history  and  a  painstaking  physical  ex- 
amination by  an  expert,  a  diagnosis  before  tubal  abortion  or  rup- 
ture is  sometimes  impossible.  Usually  the  condition  is  not  recog- 
nized in  general  practice  until  hemorrhage  has  occurred.  At  this 
time  a  history  of  early  pregnancy,  a  paroxysm  of  frightful  pain, 
sudden  collapse,  symptoms  of  internal  hemorrhage,  with  abdominal 
distention,  and  a  vaginal  examination  showing  a  pelvic  tunior 
with  possibly  the  physical  signs  of  effusion  into  peritoneal  cavity 
make  the  diagnosis  perfectly  clear,  and  indicate  an  immediate 

1  Hofmeier  claims  that  the  pulsation  of  arteries  on  one  side  of  the  cervix  and 
not  upon  the  other  is  a  valuable  sign  of  extra-uterine  pregnancy ;  and,  moreover,  that 
it  is  a  sign  of  life  in  the  ovum,  ceasing  when  the  embryo  dies  and  the  ovum  stops 
grovvfing. 

2  For  three  or  four  weeks  the  tubal  tumor  is  free;  quite  suddenly  it  sinks  into 
the  pelvis  from  its  increasing  weight,  and  wherever  it  comes  in  contact  with  the 
pelvic  peritoneum  the  latter  is  changed  into  a  decidua-like  structure  to  which  the  tube 
walls  adhere. 


EXTRA-UTERINE   PREGNANCY.  305 

celiotomy.  These  symptoms  have  been  closely  simulated  by  rup- 
ture of  a  varicose  vein  in  the  broad  ligament,  by  rupture  of  an 
ovarian  cyst  or  torsion  of  its  pedicle,  by  acute  suppurative  salpin- 
gitis, by  fulminating  appendicitis  with  intra-uterine  pregnancy,  by 
criminal  abortion  followed  by  infection,  in  which  a  false  history 
is  purposely  given,  and  by  pelvic  tumors  coincident  with  intra- 
uterine pregnancy.  But  as  all  these  conditions  demand  the  same 
treatment,  a  mistake  in  differential  diagnosis  is  not  serious. 
If  the  cramp-like  pains  of  ectopic  gestation  lead  a  patient  to 
consult  a  physician  ;  if  she  give  a  clear  history  of  impregnation  ; 
if  she  present  all  the  earlier  signs  of  pregnancy,  with  the  discharge 
of  blood  and  membrane  which  the  microscope  shows  to  be  deci- 
dual; if  there  is  a  very  sensitive  tumor  in  the  neighborhood  of 
the  uterus,  on  which  ballottement  may,  perhaps,  be  practised, 
and  if  the  uterus  is  not  so  large  as  it  should  be, — the  diagnosis 
is  justified,  and  the  necessary  treatment,  also,  involving,  as  it 
does,  a  serious  operation.  Among  the  conditions  in  the  pelvis 
that  may  make  the  diagnosis  impossible  are  :  Abortion,  in  con- 
sequence of  or  coincident  with  some  growth  near  the  uterus  ; 
pyosalpinx,  with  an  indistinct  or  untrustworthy  history  of  preg- 
nancy ;  intra-uterine  pregnancy,  with  rapid  development  of  a 
fibroid  on  one  side  of  the  uterus  ;  development  of  an  impreg- 
nated ovule  in  one  horn  of  a  unicornate  or  bicornate  uterus,  or 
on  one  side  of  a  double  uterus;  appendicitis  comphcating  intra- 
uterine pregnancy  and  cornual  pregnancy — the  implantation  of 
the  ovum  in  one  cornu  of  the  uterus,  whence  it  grows  into  the  uterine 
cavity,  but  meanwhile  causes  such  severe  paroxysms  of  pain  and 
distends  the  uterus  so  unevenly  that  interstitial  pregnancy  is  sus- 
pected. A  common  error  constantly  occurring  in  general  practice 
is  to  mistake  an  extra-uterine  pregnancy  for  an  incomplete  abortion. 
I  find  in  my  notes  of  no  cases  this  mistake  made  by  the  attend- 
ing physician  in  44.^ 

Prognosis. — Without  surgical  treatment  about  two-thirds  of 
the  cases  die;  one-third  escape  the  immediate  danger  of  death.^ 

^  It  has  been  claimed  that  acetonuria  is  alw  ays  present  in  ruptured  extra-uterine 
pregnancy  witli  intra  abdominal  hemorrhage,  and  that  this  sign,  therefore,  is  valuable 
in  the  differential  diagnosis  ;  but  acetonuria  is  so  frequent  in  intra-uterine  pregnancy 
and  other  conditions  that  I  cannot  see  its  value  as  a  diagnostic  sign  in  ectopic  gesta- 
tion (Baumgarten  and  Popper,  "  Wien.  klin.  Wochenchr.,"  No.  12,  1906).  More- 
over, it  is  not  always  j^resent  in  ectopic  jiregnancy.  In  ten  cases  I  investigated  it 
was  present  in  four,  suspicious  in  one,  and  aijsenl  in  five. 

2  In  265  cases  witliout  surgical  intervention,  36.9  per  cent,  recovered,  63.10 
per  cent,  died  (Winckel's  "  (jeburtshiilfe,"  2.  Aufl.,  S.  254).  In  loo  cases  col- 
lected by  Kiwisch,  the  mortality  was  82  per  cent.  ;  in  132  collected  by  Hecker,  42 
per  cent.  ;  in  150  by  Hennig,  88  per  cent.  ;  in  500  cases  collected  by  Parry  up  to 
1876  the  mortality  was  67.2  per  cent.  ;  in  626  cases  collected  by  Schauta,  from  1876 
to  1890,  241  ended  spontaneously,  75  in  recovery,  and  166  in  death,  a  mortality  of 
68.8  per  cent.  Martin  states  that  of  585  cases  operated  upon,  76.6  per  cent,  recov- 
ered ("Centralbl.  f.  Gyn.,"  No.  30,  1892). 


306  PREGNANCY.    ' 

Treated  by  abdominal  section,  the  mortality  should  be  about  five 
per  cent.,  or  lower  if  the  operator  sees  the  patient  in  time.  Of 
the  patients  who  do  not  die  directly  in  consequence  of  the  tubal 
gestation,  a  large  proportion  remain  invalids,  and  many  die  at  a 
remote  period  from  various  complications,  as  bowel  obstruction, 
ulceration,  suppuration,  hemorrhage. 

Treatment. — As  soon  as  the  diagnosis  is  established  with 
reasonable  certainty,  the  removal  of  the  gestation  sac  by  celiotomy 
is  the  only  treatment  worthy  of  consideration.  The  only  safe  plan 
is  either  to  operate  immediately  one's  self,  or  to  refer  the  patient 
to  a  competent  surgeon  without  delay. 

TJie  Technic  of  Abdominal  Section  for  Titbal  Pregnancy. — 
The  operation  is  often  performed  in  an  emergency,  and  must, 
therefore,  be  hurried.  Plenty  of  time,  however,  should  be  taken 
to  secure  an  absolutely  aseptic  condition  of  the  field  of  operation 
in  the  patient,  of  the  surgeon,  assistants,  dressings,  and  imple- 
ments. If  possible,  the  patient  should  be  transported  to  a  well- 
appointed  hospital.  If  there  has  been  much  bleeding  and  the 
patient's  condition  is  bad,  hypodermic  stimulation  and  submam- 
mary injection  of  salt  solution  should  precede  the  operation,  the 
anesthesia  should  be  limited  and  the  operation  should  be  fin- 
ished in  the  fewest  minutes  possible.  It  is  possible  to  conclude 
the  operation,  to  the  last  abdominal  stitch,  in  less  than  eleven 
minutes  and  with  less  than  an  ounce  of  ether.  No  attention 
should  be  paid  to  the  blood  that  gushes  in  enormous  quantities 
from  the  abdominal  cavity  when  the  peritoneum  is  incised.  It 
has  already  been  shed  and  is  of  no  use  to  the  patient.  The  side 
affected  should  have  been  learned  by  the  history,^  if  not  by  the 
physical  signs.  This  tube  should  at  once  be  grasped  between 
the  thumb  and  fingers  of  one  hand,  the  tube  should  be  cut  from  the 
cornu,  the  broad  ligament  should  be  transfixed  by  a  pedicle  needle 
to  the  inner  side  of  the  round  ligament,  and  ligated  en  masse  with 
three  turns  of  the  catgut  ligature,  one  to  each  side  of  the  pedicle 
needle,  the  third  around  the  whole  stump.  The  turns  of  the  liga- 
ture nearest  to  the  uterus  lie  under  the  severed  end  of  the  tube  so 
as  to  leave  no  stump.  The  tube  and  ovary  are  then  cut  away. 
The  cornu  is  sewed  with  a  double  tier  stitch  of  catgut.  The  ab- 
dominal cavity  is  flushed  with  a  large  quantity  of  sterile  water  ^ 

'It  is  often  impossible  to  tell  from  a  physical  examination  which  tube  is  in- 
volved, but  I  have  found  the  history  of  pain  down  one  leg  and  not  the  other  of  great 
value  in  diagnosticating  the  side  affected. 

2 1  have  practically  given  up  douching  the  abdominal  cavity  after  abdominal 
sections,  except  in  extra-uterine  pregnancy.  There  is  no  other  means  which  so 
rapidly  and  surely  removes  blood-clots  from  the  abdomen.  It  is,  moreover,  a  great 
advantage  to  leave  the  large  quantity  of  hot  water  which  remains  in  the  abdominal 
cavity  after  irrigation.  Gallons  are  required,  and  it  is  inconvenient  to  prepare  such  a 
quantity  of  normal  salt  solution.  There  is,  moreover,  no  disadvantage  in  the  use  of 
sterile  water. 


EXTRA-UTERINE   PREGNANCY.  307 

or  normal  salt  solution.  Drainage  is  rarely  necessary.  The 
author  has  not  drained  a  case  for  some  years,  though  formerly  he 
drained  every  one.  If  drainage  is  deemed  necessary,  gauze 
packing  should  be  used.  For  twelve  or  twenty-four  hours  after  the 
operation  vigorous  stimulation  and  an  active  treatment  for  the 
acute  anemia  are  necessary  if  there  has  been  profuse  hemorrhage. 
Submammary  or  intravenous  injections  of  normal  salt  solution  are 
invaluable.  If  the  operation  is  performed  before  rupture  or  after 
a  moderate  hemorrhage  from  a  tubal  abortion  its  technic  does 
not  differ  from  the  salpingectomy  for  other  indications. 

The  author  would  warn  the  inexperienced  against  waiting  for 
reaction  in  cases  of  ruptured  tubal  pregnancies  with  profuse  hem- 
orrhage. Delay  has  been  advocated,  but  could  not  be  endorsed 
by  any  one  with  a  large  and  varied  experience.  Reaction  usually 
does  not  occur.  The  patient  continues  to  bleed  until  she  bleeds  to 
death. 

The  vaginal  operation  for  tubal  pregnancy  in  the  first  three 
or  four  months  has  the  serious  disadvantages  that,  on  account  of 
uncontrollable  hemorrhage,  a  vaginal  hysterectomy  or  hasty 
abdominal  section  may  be  necessary,  and  if  the  tube  is  simply 
incised  and  not  removed,  a  diseased  and  useless  pelvic  organ  is 
left  behind  to  be  the  source  of  future  trouble.  It  is  impossible 
through  a  vaginal  incision  to  evacuate  the  blood  and  blood-clots 
lying  in  large  quantities  in  remote  portions  of  the  abdominal  cavity. 
Moreover,  as  in  all  vaginal  sections,  nicety  and  precision  of  work 
is  impossible  through  the  vaginal  vaults. 

In  interstitial  pregnancy,  on  account  of  the  difficulty  of  diag- 
nosis, treatment  is  not  usually  attempted  until  rupture  and  hem- 
orrhage have  occurred,  when  an  abdominal  section  must  be  per- 
formed. The  sac  should  be  emptied,  and  its  edges  should  be 
sewed  to  the  abdominal  wall;  after  the  bleeding  vessels  are  se- 
cured, the  sac  should  be  drained.  If  this  technic  is  impossible, 
ligation  of  the  uterine  and  ovarian  arteries  is  indicated,  drainage 
of  the  sac,  or  possibly  supravaginal  amputation  of  the  uterus. 
It  is  justifiable,  if  the  diagnosis  is  clearly  established,  to  evacuate 
the  gestation  sac  into  the  uterine  cavity  after  thorough  dilatation 
of  the  cervical  canal.  A  mistaken  diagnosis,  however,  would 
lead  to  a  premature  termination  of  a  normal  intra-uterinc  preg- 
nancy. Tait  describes  a  case  in  which  he  found  it  possible  to 
incise  the  sac,  turn  out  its  contents,  and  drain  it,  after  fetal  death.^ 
Engstrom  treated  a  case  successfully  by  incising  the  uterine  wall, 
extracting  the  dead  fetus  and  its  appendages,  making  and  enlarg- 
ing an  opening  between  the  gestation  sac  and  the  uterine  cavity, 

1  London  "  Lancet,"  1894,  i,  p.  38. 


308  PREGNANCY. 

sewing  the  uterine  wall  firmly  together,  as  after  a  Cesarean  section, 
and  closing  the  abdomen  without  drainage.^ 

Ovarian  pregnancy  is  treated  by  excision  of  the  sac  with  the 
ovary.  As  a  matter  of  fact,  the  operation  is  undertaken  in  these 
rare  cases  for  an  ovarian  tumor,  and  the  operator  discovers  its 
contents,  to  his  surprise,  after  opening  the  abdomen. 

In  advanced  extra-uterine  pregnancy  the  ]etal  sac  should  be 
enucleated  and  extracted  whole  when  the  fetus  is  viable.  It 
may  be  necessary  to  cut  the  cord  off  short,  stitch  the  sac  wall  to  the 
abdominal  wall,  and  drain  the  sac.  Forty  operations  (1889- 
1896)  after  the  seventh  month  of  gestation,  with  living  and  viable 
infants,  were  collected  by  Dr.  R.  P.  Harris.^  In  this  number 
there  were  ten  maternal  deaths;  twenty-seven  infants  survived 
the  operation.  Von  Both  has  collected  8^,  cases:  in  the  first  30 
operations  there  were  25  deaths;  in  the  53  following,  15;  and 
in  the  last  8  operations,  only  i.^  Sittner's*  statistics  show  from 
1887  to  1900  forty-eight  operations  with  removal  of  placenta 
and  fetal  sac  with  a  mortality  of  12.5  per  cent.;  thirty-five  opera- 
tions during  the  same  period  without  the  removal  of  the  placenta, 
with  a  mortality  of  42.8  per  cent.  In  the  last  five  years  of  the 
period  the  mortality  of  the  two  procedures  was  respectively  5.5 
per  cent,  and  33  per  cent.  In  a  later  article  Sittner  presents  the 
statistics  of  121  cases.  From  1901  to  1906  the  mortality  of  remov- 
ing the  whole  sac  was  5.7  per  cent.;  of  the  removal  of  the  placenta, 
leaving  the  sac  behind,  30  per  cent.  When  death  of  the  fetus  has 
occurred  the  fetus  and  its  entire  surrounding  sac  should  be  removed. 
If  the  exsection  of  the  sac  is  found  to  be  difficult  or  dangerous,  on 
account  of  hemorrhage,  the  implantation  of  the  placenta  on  the 
intestines,  or  its  inaccessibility,  it  is  permissible,  some  weeks 
after  fetal  death,  to  cut  the  cord  oft"  short,  leaving  behind  the 
atrophied  remains  of  the  placenta.  If  this  is  done,  the  sac-wall 
should  be  stitched  to  the  abdominal  wall,  and  thus  drained  for 
a  length  of  time  until  the  placenta  comes  away.  ^Meanwhile 
daily  irrigations  are  required  and  antiseptic  powders  (tannic 
or  salicylic  acid)  may  be  dusted  in  the  sac-cavity.  In  case  the 
gestation  sac  is  low  down  in  Douglas's  ^pouch,  bulging  the  poste- 
rior vaginal  wall,  vaginal  section  and  the  delivery  of  the  fetus 
by  the  natural  passage  may  be  considered ;  but  the  dangers  and 
disadvantages    of    the    vaginal    operation    should    be   carefully 

i"Centralbl.  f.  Gyn.,"  No.  5,  1S96.  Werth,  to  1904,  has  collected  31  opera- 
tions for  interstitial  pregnancy,  "  Winckel's  Handbuch,"  2^,  p.  940. 

^Kelly's  "Operative  Gynecology,"  vol.  ii. 

=* "  Centralbl.  f.  Gyn.,"  No.  15,  1899. 

*  "  Arch.  f.  Gyn.,"  Bd.  Ixiv,  Ixxxiv,  II.  i.  W.  R.  Nicholson,  "Am.  Jour. 
Obstet.,"  No.  6,  1908. 


i 


EX  TRA-  UTERINE   PRE  GNANC  Y. 


309 


weighed;  these  are:  Difficulty  of  extracting  the  fetus,  if  it  is  large, 
uncontrollable  hemorrhage,  puncture  of  an  intestine,  infection  of 
the  general  peritoneal  cavity,  either  at  the  time  of  the  operation, 
or  in  subsequent  irrigations  of  the  sac,  and  adhesions  involving 
the  uterus  and  appendages  after  the  woman's  recovery  from  the 
operation.^  Vaginal  section  is  indicated  in  case  of  an  old  gesta- 
tion sac  undergoing  suppuration  and  containing  a  much  macerated 
or  disintegrated  fetus.  In  some  cases  of  intraligamentary  preg- 
nancy it  is  possible  to  open  the  sac  extraperitoneally  by  an  inci- 
sion above  Poupart's  ligament.  It  is  always  advisable,  however, 
to  make  a  preliminary  abdominal  section  to  learn  the  relations 
of  the  gestation  sac. 

Pregnancy  in  One  Horn  of  a  Uterus  Bicornis  or  Unicornis. 
— Pregnancy  in  an  ill-developed  horn  of  a  uterus  unicornis  may 
exactly  resemble  a  tubal  or  interstitial  pregnancy,  and  will  probably 
end  in  rupture  at  the  apex  of  the  cornu."     This  is  particularly 


Fig.  210. — Pregnancy  in  the  rudimentary  horn  of  a  uterus  unicornis,  which  has 
become,  secondarily,  abdominal  (author's  collection,  Obstetrical  Museum,  University 
of  Fennsylvaniaj. 

true  if  the  impregnated  ovule  develops  in  a  rudimentary  horn, 
in  which  the  conditions  are  almost  the  same  as  in  a  tube,  except 
that  rupture  takes  place  later.  A  pregnancy  in  a  uterus  bicornis 
may  possibly  terminate  prematurely,  or  even  at  term,  by  expulsion 
of  the  product  of  conception  through  the  natural  passage.  There 
may  be  a  coincident  pregnancy  in  the  rudimentary  horn  and  in 
the  better  developed  one;  after  the  removal  of  the  former  the  latter 
may  progress  to  term.^ 

'  For  a  good  bibliography  of  the  removal  of  extra-uterine  fetuses  through  the 
vagina  and  by  the  rectum,  see  J.  T.  Winter,  "  Am.  Jour.  Obslet.,"  1892,  p.  34. 

^  Three  cases  of  pregnancy  in  rudimentary  horns  are  reported  by  Turner,  Werth, 
and  Solin  (Lusk's  "  Obstetrics  "  ).  Kussmaul  collected  thirteen  cases  ;  Mannierre  39, 
24  of  which  ended  fatally  by  rupture,  "Am.  Gyn.  and  Obst.  Jour.,"  vol.  xv,  No.  3. 
Werth  gives  the  number  published  to  1904  as  an  even  hundred,  "  Winckel's  Iland- 
buch,"  2^  p.  984. 

^Doran,  "  Journ.  of  Obst.  and  Gyn.  of  the  Hr.  Empire,"  June,  1906. 


3IO  PREGNANCY. 

The  diagnosis  of  pregnancy  in  a  uterine  horn  is  difficult  or 
impossible.  It  is  mistaken,  usually,  for  tubal  gestation.  The 
removal  of  a  gestation  sac  in  a  rudimentary  uterine  horn  is 
commonly  easy,  as  a  convenient  pedicle  is  formed  by  the  attach- 
ment of  the  horn  to  the  lower  segment  of  the  better-formed  half 
of  the  uterus. 

Hydrorrhea  Gravidarum. — A  watery  discharge  from  the 
vagina  of  a  pregnant  woman  may  have  four  sources  :  catarrhal 
endometritis,  rupture  of  the  membranes,  discharge  of  fluid  from 
a  hydrosalpinx  {liydrops  tiibce  profliiens)^  and  edema  of  the  uterine 
walls.  The  last  is  a  very  rare  cause  indeed,  and  I  am  somewhat 
skeptical  as  to  the  possibility  of  serum  leaking  from  the  uterine 
walls,  but  it  has  apparently  happened  in  a  few  cases.^  In 
catarrhal  endometritis  the  fluid  is  discharged  suddenly  in  con- 
siderable quantities  ;  it  reaccumulates  and  is  again  discharged, 
the  recurrent  hydrorrhea-  continuing,  perhaps,  until  term,  al- 
though usually  after  the  second  or  third  discharge  labor  is 
brought  on.  The  fluid  discharged  in  a  case  of  catarrhal  endo- 
metritis is  thin  mucus.  In  a  typical  case  under  my  observation 
there  was  a  discharge  of  more  than  a  pint  of  fluid  at  the  seventh 
month  of  pregnancy,  while  the  patient  was  lying  quietly  in  bed. 
It  was  supposed  that  the  membranes  had  ruptured  and  that  labor 
was  imminent,  but  no  pains  appeared,  and  after  confinement  to  bed 
for  a  week  the  patient  was  allowed  to  get  up.  A  month  later  there 
was  another  profuse  discharge, — certainly  more  than  a  pint, — 
again  occurring  while  the  patient  was  quietly  at  rest  in  bed.  Twelve 
hours  later  labor-pains  appeared  ;  in  the  latter  part  of  the  second 
stage  of  labor  the  membranes  ruptured  and  about  a  quart  of 
liquor  amnii  was  discharged.  A  careful  examination  of  the 
membranes  failed  to  detect  a  perforation  remote  from  the  seat  of 
rupture. 

Rupture  of  the  membranes  and  the  discharge  of  liquor  amnii 
in  pregnancy  are  commonly  followed  by  labor-pains  within  thirty- 
six  hours.  It  is  not  very  unusual,  however,  for  three  or  four 
days  to  elapse  from  the  time  of  rupture  to  the  onset  of  labor.  I 
have  several  times  seen  a  month  intervene  between  the  rupture 
of  the  membranes  and  the  beginning  of  labor,  and  in  one  case 
under  my  care  the  membranes  were  perforated  at  four  and  one- 
half  months  without  inducing  labor.  The  patient  was  the  wife 
of  an  English  officer  in  India.  She  had  been  told  by  a  skilful 
Indian  masseuse  that  she  was  pregnant,  but  an  English  physician 

1  "  Hydrorrhoea  Gravidarum  and  Hydrosalpinx,"  Cowles,  "  Obstetrics,"  Nov., 
1899. 

2  Chazan,  "  Centralblatt.  f.  Gyn.,"  No.  5,  1894,  p.  105. 


EXTRA-UTERINE   PREGNANCY.  3II 

whom  she  consuhed  assured  her  she  was  not,  and,  to  prove  that 
he  was  correct,  inserted  a  sound  into  the  uterine  cavity.  There 
was  immediately  a  gush  of  hquor  amnii.  In  spite  of  a  journey 
of  some  1 500  miles  from  the  interior  to  the  coast,  the  long  voy- 
age from  India  to  England,  and  thence  to  the  United  States, 
liquor  amnii  flowing  from  the  vagina  at  every  roll  of  the  ship  or 
jolt  of  a  carriage,  labor  did  not  appear  until  term,  four  and  a 
half  months  from  the  time  the  membranes  were  punctured. 
There  was  found,  after  delivery,  a  round,  regular  opening  in  the 
membranes,  about  the  caliber  of  a  lead -pencil,  midway  between 
the  seat  of  rupture  and  the  placenta,  which  was  attached  at  the 
fundus. 


PART  II. 

THE  PHYSIOLOGY  AND  MANAGEMENT  OF  LABOR 
AND  OF  THE  PUERPERIUM. 


CHAPTER  1, 
Labor. 


This  chapter  deals  with  an  important  practical  subject, — the 
management  of  a  woman  in  labor.  The  questions  involved  in 
this  study  confront  every  practitioner  of  medicine  at  some  time. 
Every  physician  is  popularly  supposed  to  be  able  to  manage  a 
labor,  and  such  cases  are  among  the  first  that  he  is  called  upon 
to  attend.  To  a  beginner  in  obstetric  practice  there  is  much  that 
is  embarrassing.  The  novel  and  intimate  relations  with  his 
patient ;  her  evident  dread  of  the  necessary  examinations  more 
or  less  revolting  to  every  woman  ;  the  doctor's  keen  conscious- 
ness of  a  lack  of  experience ;  mistrust  of  his  capacity  to  re- 
cognize the  stage  of  labor,  the  presentation  and  position  of  the 
fetus;  the  knowledge  that  his  every  movement  is  watched  by 
critical  friends  or  attendants  of  the  patient,  who  possess,  perhaps, 
just  what  he  lacks, — practical  experience, — all  unite  to  produce  a 
most  unenviable  frame  of  mind  in  the  practitioner  attending  his  first 
few  cases  of  labor.  Some  consolation,  however,  can  always  be 
found  in  the  reflection  that  labor  is  a  natural  and  a  comparatively 
easy  process,  in  the  large  majority  of  cases;  that  a  physician's 
duty  is  one  mainly  of  inaction  and  non-interference,  and  that  most 
probably  the  labor  will  terminate  fortunately  for  mother  and 
child,  in  spite  of  his  inexperience.  But  it  is  evident  that  no  one 
can  predict  what  may  occur  in  any  given  case.  There  may  sud- 
denly arise  some  accident  of  the  gravest  nature,  which  must  be 
immediately  recognized  and  promptly  treated.     It  is  under  such 

312 


LABOR.  313 

circumstances  that  a  physician's  education  and  knowledge  are 
put  to  the  test.  It  is  plain,  therefore,  that  in  a  work  on  obstet- 
rics it  must  be  the  writer's  aim  to  impart  the  requisite  knowl- 
edge to  cope  with  all  sorts  of  dangerous  emergencies.  This 
consideration  makes  it  necessary  to  dwell  at  length  upon  all  the 
possible  complications,  accidents,  and  difficulties  of  the  child- 
bearing  process,  leaving  upon  the  student's  mind  the  impression 
that  parturition  is  a  more  dangerous  process  than  is  really  the 
case.  It  is  well  to  recollect,  therefore,  that  nature  alone,  in  the 
majority  of  cases,  with  very  little  artificial  aid,  is  capable  of  termi- 
nating safely  the  birth  of  the  child;  but  at  the  same  time  it  should 
not  be  forgotten  that  at  any  moment  a  dangerous  complication 
may  occur,  which  must  be  immediately  recognized  and  promptly 
dealt  with. 

It  is  convenient  to  begin  the  study  of  labor  with  a  definition 
of  the  process. 

Labor  is  that  natural  process  by  which  the  female  expels 
from  her  uterus  and  vagina  the  ovum  at  its  period  of  full 
maturity,  which  is  reached,  on  the  average,  two  hundred  and 
eighty  days  after  the  first  day  of  the  last  menstruation.  The 
process  is  divided  into  three  main  stages  or  acts, — the  expansion 
of  the  birth-canal,  the  expulsion  of  the  fetus,  and  the  delivery 
of  the  remainder  of  the  ovum. 

Why  labor  occurs  at  the  end  of  two  hundred  and  eighty  days 
has  given  rise  to  endless  speculation  in  all  ages  of  medicine.^ 
Several  explanations  may  be  offered.  The  period  of  two  hundred 
and  eighty  days,  or  forty  weeks,  or  ten  lunar  months,  must  at  once 
direct  attention  to  the  fact  that  labor  comes  on  at  the  tenth  men- 
strual period  since  pregnancy  began.  At  the  menstrual  period  in 
the  non-pregnant  uterus  there  is  always  distinct  muscular  action, 
induced  probably  by  the  presence  of  a  foreign  body — blood — 
in  the  uterine  cavity.  During  pregnancy  it  has  long  been  known 
that  by  the  unconscious  memory  of  living  tissue  there  recurs,  at 
regular  intervals  corresponding  to  the  menstrual  period,  a  dis- 
position to  muscular  action,  which  is  sometimes  so  exaggerated 
as  to  bring  about  an  expulsion  of  the  ovum, — an  accident  especially 
to  be  feared  at  such  times  in  women  prone  to  abort.  This  cause 
of  labor  is  described  conveniently  as  periodicity. 

^  Hippocrates  explained  the  onset  of  labor  by  the  hunger  of  the  fetus,  which  im- 
pelled it  to  make  its  exit  from  the  womb  to  seek  something  to  eat.  The  following 
explanations  have  been  offered  in  recent  times :  thrombosis  of  the  veins  at  the  placenta 
site  ;  excess  of  CO2  in  the  maternal  blood  ;  excess  of  CO._,  in  the  fetal  blood  ;  defi- 
ciency of  CO2  in  the  blood ;  pressure  upon  the  ganglia  in  the  supravaginal  portion  of 
the  cervix ;  excess  of  urea  in  the  blood,  etc.  See  Blumreich,  "  Experimente  Zur 
Frage  nach  den  Ursachen  des  Geburtseintrittes,"  "  Arch.  f.  Gyn.,"  Bd.  Ixxi,  H.  I. 


314  LABOR  AND    THE    PUERPERIUM. 

The  hollow  muscles  in  the  body  admit  of  distention  up  to  a 
certain  point,  but,  that  point  being  reached,  they  are  immediately 
stimulated  to  contraction.  This  is  well  illustrated  in  the  stomach 
of  the  young  infant,  which  nurses  until  the  organ,  overfilled, 
contracts  and  expels  the  excess  of  food  which  its  cavity  cannot 
contain.  The  same  action  is  seen  in  the  pregnant  uterus.  It 
admits  of  distention  up  to  a  certain  point,  until  it  is  well  filled  by 
the  mature  fetus,  when  the  great  tension  of  its  walls,  no  longer 
endurable,  stimulates  them  to  muscular  action  which  terminates 
in  the  expulsion  of  the  ovum.  This  cause  of  labor  is  defined  as 
over  distention  of  the  uterus. 

In  the  human  ovum  that  has  reached  full  maturity  there 
occurs  a  degenerative  process,  a  fatty  change,  in  the  connections 
which  bind  the  ovum  to  the  uterus,  that  brings  about  a  separa- 
tion more  or  less  extensive  between  the  uterine  wall  and  the  ovum, 
and  the  latter,  becoming  a  foreign  body  in  the  uterine  cavity,  is 
cast  off. 

This  cause  of  labor  is  called  the  maturity  of  the  ovum. 

Finally,  heredity,  the  unconscious  memory  of  tissue  trans- 
mitted from  generation  to  generation,  plays  an  important  role 
in  the  causation  of  labor.  Thus,  at  the  end  of  two  hundred 
and  eighty  days  the  fetus  has  reached  such  a  size  that  it  is  just 
possible  for  the  woman,  at  the  expense  of  much  effort,  to  expel  it 
through  the  birth-canal.  Had  it  grown  much  larger,  its  expul- 
sion would  be  difficult  or  impossible.  On  the  other  hand,  an 
infant  born  much  before  two  hundred  and  eighty  days  is  not 
sufficiently  well  developed  to  endure  the  lower  temperature  that 
it  encounters,  and  the  necessity  for  obtaining  its  own  nourish- 
ment and  oxygen,  and  consequently  it  may  not  survive.  There- 
fore, it  is  plain  that  only  those  women  who  gave  birth  to  their 
offspring  about  the  two  hundred  and  eightieth  day  of  pregnancy 
could  successfully  perpetuate  the  human  species.  Those  that 
fell  in  labor  later  probably  died  ;  those  whose  young  were  bom 
earlier  were  not  able  to  rear  them  ;  and  so  the  habit  of  bear- 
ing children  at  the  end  of  forty  weeks  from  conception,  trans- 
mitted from  generation  to  generation  through  many  ages,  became, 
perhaps,  the  most  powerful  influence  in  determining  the  duration 
of  pregnancy. 

To  recapitulate,  then,  labor  comes  on  at  about  the  two  hundred 
and  eightieth  day  from  the  beginning  of  the  last  menstrual  period, 
by  reason  of  the  influence  of  periodicity ;  the  overdistention  of 
the  uterine  cavity;  the  maturity  of  the  ovum,  and  heredity.  AH 
these  causes  being  operative  together,  it  requires  a  slight  stimulus 
or  none  at  all  to  inaugurate  effective  uterine  contractions.     Ex- 


LABOR.  "  315 

ercise,  a  dose  of  purgative  medicine,  a  jolt  or  a  jar  may  provoke 
muscular  action  on  the  part  of  the  uterus  that  ends  in  the  expulsion 
of  the  child.  This  knowledge  is  sometimes  put  to  practical  use. 
If  it  is  desirable  that  labor  should  not  be  delayed,  a  dose  of  castor 
oil  the  night  before  the  expected  date  and  15  grains  of  quinin  the 
next  morning,  especially  in  primiparae,  often  bring  on  effective 
pains. 

Before  entering  upon  a  study  of  labor  the  student  should  be 
sure  that  he  is  able  to  recognize  its  occurrence. 

The  diagnosis  of  labor,  therefore,  is  a  necessary  preface  to 
the  study  of  its  physiology  and  management.  First  and  fore- 
most, in  the  woman  supposed  to  be  in  labor,  the  existence  of 
pregnancy  should  be  determined.  Many  ludicrous  and  some 
tragic  errors  have  been  due  to  a  disregard  of  this  rule.^  There 
is  a  valuable  premonitory  sign  of  labor  which  should  always  be 
inquired  for:  the  subsidence  of  the  uterine  tumor  at  periods  vary- 
ing from  four  weeks  in  the  primigravida  to  two  weeks  or  less  in 
the  multigravida  before  the  actual  advent  of  labor.  This  sink- 
ing of  the  uterine  tumor  is  the  result  of  the  engagement  of  the 
lower  uterine  segment  with  the  presenting  part  of  the  fetus  in 
the  superior  strait  and  in  the  cavity  of  the  pelvis.  It  has  its 
cause,  probably,  in  the  action  of  the  muscles  inclosing  the  ab- 
dominal cavity.  Just  as  the  stomach,  the  heart,  and  the  uterus 
bear  distention  up  to  a  certain  point,  so  the  abdominal  mus- 
cles allow  a  certain  distention  of  the  abdomen  to  occur,  but 
resent  anything  beyond  it.  This  point  is  reached  in  primi- 
gravidae  at  about  the  thirty-sixth  week  of  pregnancy,  but  later 
in  multigravidae  owing  to  a  greater  laxity  of  their  muscles. 
The  abdomen  being  distended  to  its  utmost,  the  abdominal  mus- 
cles contract  vigorously  and  drive  the  lower  part  of  the  uterus 
down  through  the  superior  strait  into  the  cavity  of  the  pelvis  by 
diminishing  the  area  of  intra-abdominal  space,  thus  accomplish- 
ing the  first  step  in  the  expulsion  of  the  child,  the  passage  of 
the  head,  presuming  it  to  be  a  cephalic  presentation,  through 
the  superior  strait,  long  before  the  labor  itself  begins.  This 
sinking  of  the  fetus  and  uterus  occurs  often  suddenly,  so  that 
the  pregnant  woman  may  rise  one  morning  entirely  relieved  of 
the  distressing  abdominal  pressure  symptoms  that  had  previously, 

1  One  of  my  students,  on  duty  in  the  out-patient  obstetric  department,  receiving 
his  first  call,  hurried  to  the  woman's  house,  spent  some  fifteen  minutes  sterilizing  his 
hands,  and  made  a  prolonged  vaginal  examination,  much  to  the  patient's  surprise,  as 
she  had  sent  for  a  physician  on  account  of  rheumatism.      She  was  not  pregnant. 

On  one  occasion  I  figured  as  an  expert  witness  in  a  trial  for  damages  on  account 
of  an  attempted  Cesarean  section.  The  patient,  a  rachitic  dwarf,  was  not  even  preg- 
nant when  the  operation  was  performed. 


3l6  LABOR  AND    THE   PUERPERIUM. 

perhaps,  tormented  her.  But  the  rehef  in  one  direction  is  fol- 
lowed by  an  aggravation  of  the  varices  about  the  vulva,  anus, 
or  lower  limbs,  by  neuralgic  pains  extending  down  the  thighs, 
by  increased  vaginal  secretion, — all  due  to  the  greater  pressure 
within  the  pelvic  cavity.  So  constant  is  this  phenomenon,  the 
descent  of  the  pregnant  uterus  near  term,  that,  should  it  fail  to 
occur,  some  cause  for  the  failure  should  be  looked  for.  It  is 
usually  found  to  be  a  malposition  of  the  fetus  or  a  deformity 
of  the  pelvis. 

There  are  three  signs  indicating  that  labor  has  actually 
begun:  (i)  Recurrent  pains  of  characteristic  duration,  situation, 
and  nature  ;  (2)  the  escape  of  a  small  quantity  of  blood-tinged 
mucus  from  the  vagina,  and  (3)  the  dilatation  of  the  os.  The 
characteristic  pains  of  commencing  labor  recur  at  intervals  of 
from  five  minutes  to  half  an  hour,  usually  being  about  fifteen 
minutes  apart.  The  pain  is  located  in  the  abdomen,  or  is  de- 
scribed as  passing  from  the  umbilicus  in  front  to  the  sacrum 
behind,  or  in  some  cases  is  confined  altogether  to  the  back. 
It  comes  on  suddenly.  The  woman  is  walking  about  the 
room,  or  perhaps  conversing,  when  suddenly  she  pauses, 
bends  over,  contorts  the  facial  muscles,  sets  her  lips,  and 
clinches  her  teeth.  The  pain  rarely  lasts  more  than  a  minute; 
when  it  passes  off  the  woman  resumes  her  interrupted  occupa- 
tion. If  the  hand  were  laid  over  the  abdomen  when  the  pain 
came  on,  the  uterus  would  be  felt  as  a  firm,  hard,  well-defined 
body,  more  globular  than  in  its  relaxed  condition. 

As  a  consequence  of  the  dilatation  of  the  internal  os,  the 
lower  portion  of  the  ovum  begins  to  sever  its  connection  with 
the  uterine  wall,  small  blood-vessels  are  torn,  and  there 
is  a  slight  oozing  of  blood,  which  stains  the  large  plug  of 
tenacious  mucus  that  has  filled  the  cervical  canal  during  preg- 
nancy. The  cervix  being  gradually  obliterated  from  above 
downward  by  the  descending  ovum,  the  blood-stained  plug  of 
mucus  is  expelled  from  the  cervix  into  the  vagina,  whence  it 
escapes  externally  and  becomes  what  is  popularly  called  the 
show,  which  is  regarded,  and  rightly,  too,  as  a  valuable  sign  of 
beginning  labor.  But  the  uterus  may  contract  quite  vigorously 
and  bloody  mucus  may  escape  externally  in  many  a  case  when 
labor  has  not  really  begun.  The  most  reliable  sign,  after  all,  is 
the  obliteration  of  the  cervical  canal  and  the  dilatation  of  the 
OS.  If  these  conditions  become  plainly  appreciable,  one  may 
safely  diagnosticate  a  beginning  labor,  although  it  would  be 
well  to  bear  in  mind  exceptional  cases  in  which  the  os  has 
actually   dilated    up   to   an   inch    or  more,    but    has   afterward 


LABOR.  317 

retracted  and  remained  undilated  until  true  labor  finally  ap- 
peared.^ 

Having  made  a  diagnosis  of  beginning  labor,  the  physician 
is  immediately  plied  with  questions  by  the  patient  or  her 
family  as  to  its  probable  duration.  This  is  a  question  that  is 
put  to  ever}^  practitioner  of  obstetrics  in  almost  every  case,  but, 
unfortunately,  it  can  not  be  given  a  definite  answer.  It  is  a 
common  experience  to  see  a  variation  in  the  length  of  labor  from 
one  hour  or  less  to  many  hours  ;  indeed,  in  rare  cases  to  a  week 
or  more.  So  that  it  is  impossible  to  predict  with  any  degree  of 
accuracy  how  long  a  given  labor  might  last.  One  can  usually 
obtain  an  approximate  idea,  however,  by  bearing  in  mind  the 
average  duration  of  labor  in  multiparae,  eight  hours,  while  in 
primiparse  the  time  is  usually  double  that  or  longer.  One 
should  recollect  that  a  large  parturient  canal  with  a  normal  fetus, 
or  one  undersized,  along  with  vigorous  muscular  action,  means 
a  quick  labor  ;  that  the  opposite  conditions  mean  delay.  In  the 
case  of  multiparae  one  should  always  inquire  into  the  history  of 
past  labors,  for  many  women  have  marked  individual  peculiari- 
ties in  regard  to  the  duration  of  parturition,  in  some  the  process 
being  usually  rapid  and  easy,  in  others  the  reverse.  A  consid- 
eration of  all  these  factors  will  enable  one  to  form  some  definite 
idea  in  his  own  mind  of  the  probable  duration  of  labor,  but 
he  would  do  wisely  to  keep  his  opinion  to  himself.  To  the  in- 
cjuiring  family  a  non-committal  statement  should  be  made,  such 
as  "the  length  of  the  labor  will  depend  on  the  strength  of  the 
pains."  ^ 

Before  proceeding  to  a  consideration  of  the  management  of 
labor,  the  student  will  find  it  of  service  to  observe  the  process 
as  a  passive  spectator.  Nothing  is  so  conspicuous  in  the  first 
stage  of  labor  as  the  contractions  of  the  uterine  muscle.  It  has 
been  asserted  that  the  uterine  walls  contract  in  a  sort  of  peris- 
taltic wave,  beginning  at  the  cervix,  running  up  over  the  fundus, 
and  returning  again  to  the  cervix  ;  but  this  action  has  never  been 
actually  demonstrated,  and  it  is  more  convenient,  if,  indeed,  it  is 
not   strictly  correct,   to    regard   the   uterus  as  a  hollow  muscle 

1  I  have  seen  a  young  primigravida  with  the  os  dilated  so  that  I  could  put  four 
fingers  side  by  side  into  it,  and  with  the  membranes  bulging  into  the  vagina,  who 
walked  about  the  house  for  a  week  in  this  condition  before  labor-pains  appeared.  In 
this  and  in  similar  cases,  however,  the  cervical  canal  was  not  effaced. 

2As  those  labors  which  end  in  the  day-time  often  begin  at  night,  and  vice  versd, 
an  obstetrician's  rest  is  disturbed  in  a  very  large  proportion  of  his  cases.  There  is, 
consequently,  a  prevalent  idea  that  almost  all  confinement  cases  occur  at  night.  As 
a  matter  of  fact,  forty  per  cent,  only  are  delivered  between  the  hours  of  1 1  P.  M.  and  7 
A.  M.,  according  to  the  statistics  of  West,  based  on  2019  cases  ("Amer.  Med. 
Jour.,"  1854). 


3l8  LABOR  AND    THE   PUERPERIUM. 

which  contracts  at  once  and  equally  in  all  its  parts.  The  effects 
of  these  contractions  are  :  (i)  To  drive  the  liquor  amnii  in  the 
direction  of  least  resistance,  which  is  through  the  internal  os 
into  the  cervical  canal,  where,  contained  in  the  membranes,  it 
dilates  the  cervical  canal  in  the  very  best  manner  for  the  mater- 
nal tissues,  as  a  hydrostatic  dilator.  (2)  To  drive  down  the 
fetal  mass  in  the  same  direction  by  diminishing  the  area  of  the 
intra-uterine  space.  (3)  To  distend  the  lower  uterine  segment 
and  upper  cervical  canal  by  mechanical  pressure,  and,  finally,  to 
dilate  the  os  in  the  same  manner  after  the  circular,  sphincter-like 
muscle  of  the  cervix  has  been  paralyzed  by  stretching  and  pro- 
longed pressure.  The  average  duration  of  the  uterine  con- 
tractions during  labor  is  one  minute.  The  intervals  between 
them  decrease  as  labor  goes  on,  and  the  pains  become  more 
powerful  until,  finally,  there  should  intervene  between  them  but 
two  or  three  minutes.  No  one  could  observe  the  process  of 
parturition  in  the  capacity  of  a  scientific  observer  without  re- 
garding the  action,  appearance,  and  condition  of  the  woman.  It 
will  be  found  that  her  whole  bearing  and  manner  present  two 
distinct  types  in  the  course  of  the  process.  At  first  the  advent 
of  each  pain  is  announced  by  a  sudden  setting  of  the  teeth, 
a  distortion  of  the  facial  muscles,  suffused  eyes,  and  a  flushed 
face,  and,  the  pain  increasing  in  intensit)^  she  suddenly  emits 
a  sharp  cry  of  pain.  The  woman,  if  in  bed,  assumes  almost 
any  attitude  that  is  most  comfortable  to  her.  In  a  normal 
first  labor  of  some  seventeen  hours'  duration,  this  condition 
of  affairs  lasts  about  fifteen  hours,  when  a  marked  change 
may  be  observed  in  the  woman's  action.  If  she  were  left 
entirely  to  herself  she  would  be  very  likely  to  assume  a 
squatting  posture  in  bed  or  upon  the  floor,^ — a  position  assumed 
by  the  womicn  of  many  savage  tribes  during  the  latter  stage  of 
labor.  Now,  as  a  pain  comes  on  the  woman  draws  a  deep 
breath,  clinches  her  teeth,  fixes  her  diaphragm,  and  evidently, 
from  her  behavior,  calls  into  play  the  action  of  the  abdominal 
muscles  with  all  her  might.  Her  face  is  suffused,  the  eyebrows 
knit,  and  beads  of  perspiration  stand  out  upon  her  brow.  As 
long  as  the  breath  can  be  held  this  straining  action  is  continued, 
until  the  air  is  suddenly  expelled  from  the  lungs  with  a  charac- 
teristic grunting  sound,  the  diaphragm  is  again  relaxed,  and  the 
abdominal  muscles  cease  for  a  moment  to  act  until  a  full  in- 
spiration is  taken,  when  the  straining  again  begins,  and  continues 
until  the  uterine  contraction  passes  off.  If  a  vaginal  exami- 
nation were  made  at  this  time,  a  reason  would  be  found  for  the 
change  in  the  clinical  aspect  of  the  case.  It  would  be  discovered 
that  the  os  is  fully  dilated  and  that  the  presenting  part  is  begin- 


LABOR. 


319 


ning  to  descend,  either  carrying  the  membranes  before  it  or  else, 
as  is  more  common,  the  membranes  rupture  just  as  the  os  is 


Fig.  211. — The  bag  of  waters  or  pouch  of  membranes. 


Fig.  21: 


•The  distention  of  the  vulva  and  tlie  appearance  of  the  child's  scalp. 


fully  dilated  and   the  child's  presenting  part  is  driven  through 
the  rent  in  the  amnion  and  chorion.     In  this  condition  of  affairs 


320 


LABOR  AND    THE   PUERPERIUM. 


is  found  a  good  explanation  for  the  action  of  the  abdominal 
muscles;  so  long  as  the  presenting  part  acts  simply  as  a  wedge, 
dilating  the  os,  but  not  descending  to  any  appreciable  degree,  the 
muscles  of  the  abdomen  are  useless,  and  are,  in  fact,  inhibited, 
for  their  action  would  drive  the  presenting  part  against  the  undi- 
lated  cervix  with  such  force  as  to  give  great  pain,  if  not  to  do 


Fig.  213. — The  escape  of  the  head'and  the  resumption  of  its  oblique  position 
(external  restitution). 


great  damage.  The  main  obstruction  to  the  descent  of  the 
child,  the  cervix,  being  removed,  the  abdominal  muscles  are 
called  into  play,  and  act  effectively  in  the  displacement  of  the 
fetal  body  downward  along  the  birth-canal.  For  convenience 
definite  names  are  given  to  these  stages  of  labor,  presenting 
each  such  distinctive  features.  The  period  of  dilatation  is  called 
the  first  stage  ;  the  period  of  descent  or  expulsion  is  called  the 
second  stage.  The  first  stage  begins  with  the  onset  of  labor 
and  ends  with  the  complete  dilatation  of  the  os.  The  second 
stage   begins   with    the    dilatation  of  the   os   and  ends  with  the 


LABOR. 


321 


complete  expulsion  of  the  child.  As  labor  is  not  complete  until 
the  whole  ovum  is  expelled,  there  is  a  third  stage  of  labor,  that 
period  of  time  from  the  extrusion  of  the  fetus  until  the  pla- 
centa and  membranes  are  expelled. 

To  return  to  the  clinical  phenomena  of  labor.  The  wo- 
man has  passed  from  the  first  to  the  second  stage.  As  the 
latter  progresses  the  pains  become  more  frequent  and  more 
violent,    the    suffering    is   increased,    and    her   complaints    grow 


Fig.  214. — The  transverse  rotation  of  the  head  (external  rotation). 


louder.  Finally  she  declares,  perhaps,  that  she  must  rise  to 
evacuate  her  rectum  and  bladder,  and  the  reason  for  this  feel- 
ing is  clear  when  one  sees  the  perineum  bulging  far  outward,  the 
anus  widely  dilating,  the  rectum  becoming  slightly  everted,  and 
the  presenting  part,  the  head,  filling  up  the  whole  lower  part  of 
the  pelvis  and  pressing  as  firmly  on  the  bladder  in  front  as  it 
does  on  the  rectum  behind.  And  now,  with  his  eye  upon  the 
vulva, — for   this   part   of  the  labor,  in  the  best  interests   of  the 


322 


LABOR  AND    THE  PUERPERIUM. 


patient,  ought  always  actually  to  be  observed,  both  in  a  scientific 
study  of  the  process  and  in  its  management, — the  physician  sees 
the  labia  separate  during  a  pain  and  the  child's  scalp  come  into 
view,  but,  with  the  subsidence  of  the  pain,  disappear.  With  the 
next  uterine  contraction  a  little  more  of  the  head  appears, 
again  to  disappear  as  the  pain  passes  off,  and  so  on  with 
every  pain  for  perhaps  twenty  minutes  or  an  hour,  although 
every  time,  as  more  and  more  of  the  head  appears,  it  looks  to 
the  inexperienced  observer  as  if  that  pain  must  be  the  last,  until 


Fig.  215. — The  support  of  the  head  and  the  escape  of  the  anterior  shoulder. 

finally  the  vulva  is  stretched  to  its  utmost  limit  and  the  largest 
diameters  of  the  head  are  engaged,  when,  with  a  sudden  shriek 
of  pain  from  the  woman,  the  child's  head  is  born.  There  comes 
then  a  pause  in  the  uterine  action  ;  the  head  may  protrude  from 
the  vagina  for  a  minute  or  much  longer,  while  the  woman's 
natural  powers  are  being  recuperated,  after  their  tremendous  ex- 
ertion, for  a  fresh  effort.  Meanwhile,  the  child's  face  turns  im- 
mediately after  birth  toward  one  or  the  other  tuber  ischii,  and 
from  the  constriction  about  the  neck  becomes  livid,  and  it  seems 
that  the  child's  life  is  threatened  by  strangulation.  The  medi- 
cal attendant  feels  at  first  an  almost  irresistible  impulse  to  pull 
on  the  head  and  terminate  labor.  But  this  is  a  useless,  indeed, 
a  reprehensible  procedure,  for  the  child  is  perfectly  safe,  its 
respiration   still   going  on  normally  in  the  placenta,  and  to  ex- 


LABOR.  323 

tract  the  shoulders  rapidly  through  the  overstretched  and 
bruised  maternal  tissues  is  almost  certain  to  lacerate  the  peri- 
neum. Moreover,  the  child  is  insensible  at  this  time  ;  it  has 
been  almost  comatose  during  its  passage  through  the  pelvic  canal, 
and  is  now  recovering,  its  brain-centers,  especially  that  of  respi- 
ration, becoming  ready  to  respond  to  the  stimulus  to  act  when 
the  child  is  born.  Any  unnecessary  interference,  therefore,  at 
this  stage  of  labor  may  harm  both  mother  and  child.  The 
woman's  uterus  having  regained  power,  in  a  few  minutes  begins 
to  contract.  The  abdominal  muscles  aid  it.  The  child's  face 
turns  still  more  to  one  side  or  the  other  until  it  looks  quite 
transverse.  The  expulsive  force  still  acting,  the  anterior  shoulder 
appears  under  the  symphysis  pubis,  the  posterior  shoulder 
shortly  afterward  sweeps  over  the  perineum  and  escapes  ;  the 
anterior  shoulder  follows  it,  and  the  rest  of  the  body,  too  small 
to  present  any  longer  an  effective  resistance,  is  expelled  im- 
mediately and  the  child  is  born.  Its  birth  is  announced,  as 
a  rule,  at  once  by  a  lusty  cry,  which  expands  its  lungs  and 
initiates  the  pulmonary  respiration.  Immediately  after  the  ex- 
pulsion of  the  child  the  woman  becomes  perfectly  quiet  and 
composed,  no  matter  how  noisy  she  may  have  been  before. 
The  passive  pleasure  of  relief  from  suffering  is  so  great  that 
it  becomes  a  positive  enjoyment  simply  to  be  quiet,  and  the 
woman  does  not  wish  to  be  disturbed.  In  the  course  of 
some  fifteen  or  twenty  minutes,  in  a  perfectly  natural  and 
normal  case,  such  as  is  now  under  description,  the  patient  again 
experiences  pain  ;  the  uterus  is  again  contracting,  and  the  woman 
is  again  instinctively  aiding  it  with  her  abdominal  muscles,  until 
after  one  or  two  such  pains  the  placenta  with  the  membranes  is 
expelled. 

The  manner  in  which  the  placenta  is  separated  from  the 
uterine  wall  and  is  expelled  from  the  uterine  cavity  is  a  matter 
still  under  dispute,  and  there  is  the  greatest  difference  of  opinion 
in  regard  to  it.  "  If,"  says  Dr.  Berry  Hart,  the  distinguished 
obstetrician  of  Edinburgh,  "the  delivery  of  the  placenta  de- 
pended upon  obstetricians  knowing  how  it  separated,  no  woman 
in  labor  would  complete  her  third  stage."  To  explain  the  first 
phenomenon,  the  separation  of  the  placenta,  many  theories  have 
been  advanced,  of  which  I  shall  giN'e  only  the  three  most  reasonable, 
each  of  which  has  its  prominent  adherents.  These  three  theories 
are:  (i)  The  diminution  in  the  area  of  the  placental  site;  (2) 
the  detrusion  theory,  which  is  founded  on  the  belief  that  the  uterus 
seizes  the  placenta  and  pushes  it  off  from  the  uterine  wall; 
and  (3)  the  theory  that  an  effusion  of  blood  occurs  behind  the 
placenta,  and  that  this  "  retroplacental  effusion,"  as  it  is  called, 


324  LABOR  AND    THE   PEURPERIUM. 

pushes  off  the  placenta  from  the  uterine  wall.  Of  these  three 
theories,  I  am  an  adherent  of  the  first.  In  a  strictly  normal  case 
the  retraction  of  the  placental  site  is  alone  sufficient  to  account 
for  the  separation  of  the  placenta.  It  has  been  demonstrated 
that,  as  the  uterus  contracts,  the  placenta  follows  the  retrac- 
tion of  the  uterine  walls  up  to  a  certain  point  without  becom- 
ing detached,  until  the  placenta  is  reduced  to  about  one-half 
its  natural  size.  Now,  this  is  easily  explained  if  one  recol- 
lects the  structure  of  the  placenta,  like  a  sponge,  with  its  branching 
villi  and  intervening  blood-spaces.  But  as  soon  as  these  villi  are 
squeezed  together  so  that  the  placenta  forms  one  solid  mass,  it 
can  no  longer  follow  the  retraction  of  the  uterine  wall,  but  is  that 
moment,  in  a  typically  normal  case,  sprung  off  from  its  attachment 
to  the  uterus,  and  is  for  a  varying  period  of  time  loose  within 
the  uterine  cavity,  until,  acting  as  an  irritating  foreign  body 
upon  the  uterus,  it  is  finally  driven  out  into  the  cervical 
canal  and  upper  part  of  the  vagina  by  the  uterine  contractions 
that  its  presence  within  the  uterus  excites.  In  the  cervix  and 
vagina,  however,  the  placenta  may  remain  a  long  time  without 
exciting  the  benumbed  and  almost  paralyzed  muscles  of  these 
regions  to  action.  And  thus  it  is  that,  in  civilized  women,  at 
least,  it  is  often  impossible  to  leave  the  third  stage  of  labor 
entirely  to  nature,  for  the  placenta  may  remain  so  long  undeliv- 
ered that  its  succulent  mass  may  putrefy  and  so  become  a 
source  of  septic  infection.  In  describing  a  perfectly  normal  case 
of  labor,  I  must  presume  that  the  placenta  is  expelled  by  the 
natural  forces,  and  must  describe  the  manner  of  its  expulsion. 
But  here,  again,  one  encounters  the  greatest  difierence  of  opinion, 
even  about  so  apparently  simple  and  trivial  a  matter.  One 
set  of  observers,  led  by  the  English  obstetrician,  Matthews 
Duncan,  declares  that  in  natural  labor  the  placenta  comes  out 
edgewise,  and  that  any  other- mode  of  exit  indicates  something 
abnormal ;  while  Schultze,  of  Germany,  and  his  followers  de- 
clare that  the  placenta  always  escapes  like  an  inverted  umbrella. 
My  observation  compels  me  to  adopt  the  latter  view. 

In  consequence  of  the  enormous  effort  put  forth,  the  nervous 
excitation,  the  acute  suffering,  and  the  injury  inflicted  upon  the 
soft  structures  of  the  birth-canal,  it  is  not  surprising  that  sys- 
tematic thermometry  of  the  recently  delivered  woman  shows 
almost  always  some  elevation  of  temperature  in  the  first  twelve 
or  twenty-four  hours  after  child-birth. 

After  a  brief  observation  of  the  main  clinical  phenomena  of 
labor,  the  student  is  better  prepared  to  take  up  a  consideration  of 
its  management.  The  advice  offered  applies  to  private  and  not 
to  hospital  practice,  and  to  the  beginning  of  the  process.      In 


LABOR.  325 

the  vast  majority  of  cases  a  physician  is  engaged  to  attend 
a  woman  in  confinement  a  considerable  length  of  time  before 
labor  is  expected,  and  there  are  points  in  the  preliminary 
management  of  the  patient  which  it  is  important  to  appre- 
ciate, but  they  have  been  considered  in  the  section  upon  the 
management  of  pregnancy.  The  present  section  begins  with 
the  first  intimation  that  the  doctor  receives  of  beginning  labor, 
the  summons  to  attend  his  patient  in  confinement.  The  call 
may  come  at  the  most  inconvenient  time, — late  at  night ;  in  the 
early  hours  of  the  morning  ;  at  the  beginning  of  a  meal ;  in  the 
midst  of  a  press  of  other  work, — but  no  one  should  practise  ob- 
stetrics who  does  not  make  it  an  inflexible  rule  to  give  such 
a  summons  precedence  over  everything,  over  personal  con- 
venience and  all  other  engagements. 

It  is  customary,  in  this  connection,  to  offer  advice  to  young 
practitioners  in  regard  to  their  personal  demeanor  and  appear- 
ance when  about  to  attend  a  woman  in  labor.  While  such  ad- 
vise is  usually  superfluous,  it  does  no  harm  to  remind  the  phy- 
sician of  the  especial  requirements  of  obstetric  practice.  He 
should  remember  that  the  irritability  and  increased  sensibility 
characteristic  of  pregnancy  are  even  more  exaggerated  during 
labor.  Any  unusual  appearance  in  the  medical  man — slovenliness 
of  dress,  abruptness  of  speech  and  manner,  harshness  of  voice, 
the  odor  of  liquor  on  his  breath  or  of  tobacco  in  his  clothing 
— may  disgust  his  patient.  Bearing  in  mind  the  increased  sensi- 
tiveness of  women  in  labor,  recollecting  that  the  agony  which  they 
are  about  to  endure,  and  that  the  despondency  due  to  dread  of  im- 
pending suffering,  if  not  of  death,  demand  the  greatest  sympathy 
and  consideration,  no  one  fitted  by  nature  for  the  practice  of  medi- 
cine will  go  far  astray  in  his  conduct  toward  his  parturient  patients. 

A  more  important  question  arises  as  soon  as  a  physician 
is  summoned  to  a  case  of  labor.  What  shall  he  take  with 
him  ?  As  a  part  of  his  management  of  the  pregnant  woman  he 
has  directed  the  patient  or  her  friends  to  have  at  hand  the 
articles  enumerated  in  the  list  of  directions  to  mother  and  nurse 
on  pages  374-376.  A  well-equipped  obstetrician  should  take 
with  him  in  his  obstetric  bag,  to  an  ordinary  case  of  confinement, 
the  following  articles: 

1  razor. 

Nest  of  basins  (3). 

2  brushes.     4  towels. 

I  metal  tube  for  sterile  cotton,  vulva  pads  and  packing. 
I  gown. 

1  tube  unguent. 

2  pair  rubber  gloves. 


326  LABOR   AND    THE   PUERPERIUM. 

I  clinical  thermometer. 
I  hypodermic  syringe. 

I  douche  bag,  glass  nozzle,  and  rectal  tube. 
I  bottle  containing  eye  wipes,  pipet,  and  boric  acid  solution 
(gr.  XV  to  oz.). 

I  jar  containing  umbilical  tape. 
I  jar  containing  soft  soap. 

1  bottle  ergot. 

2  ampoules  of  ergotin  for  hypodermic  injection. 
I  bottle  nitrate  of  silver  (i  per  cent.). 

I  bottle  bichlorid  tablets. 

I  powder  shaker,  containing  powder  for  umbilical  dressing  (i 
part  salicylic  acid  to  8  parts  starch). 
I  package  of  umbilical  cord  dressing. 
I  sterile  catheter. 
I  hypodermoclysis  needle. 
I  bottle  tablets  for  making  normal  salt  solution. 

CONTENTS    OF    INSTRUMENT    PAN. 

I  pair  Simpson's  forceps.  i  tube  catgut. 

I  tenaculum  forceps.  i  dressing  scissors.    • 

1  intra-uterine  catheter.  i  umbilical  scissors. 

2  hemostatic  forceps.  Alcohol  lamp  and  stand. 

1  curet  forceps.  Small  instrument  tray. 

2  needles. 

This  is  the  equipment  furnished  my  students  in  the  outpatient 
department  of  the  University  Hospital.  The  basins,  brushes, 
towels,  gown,  gloves,  douche  bag,  cord  dressing,  and  catheter  are 
done  up  in  separate  packages,  covered  with  muslin,  and  sterilized 
in  the  autoclave.  The  metal  tube  and  powder  shaker,  with  their 
contents,  are  also  sterilized. 

Arrived  at  the  dwelling  to  which  he  has  been  summoned, 
the  physician  finds  the  woman  in  the  room  selected  for  her  con- 
finement, which  should  be,  if  possible,  the  sunniest  and  best 
ventilated  in  the  house,  and  in  care  of  a  nurse  in  w^hom  he  has 
confidence  from  past  acquaintance  or  from  good  recommenda- 
tion. He  has  been  summoned  because  the  w^oman  believes  her- 
self to  be  in  labor,  but  she  may  be  mistaken,  or,  on  the  other 
hand,  may  be  much  farther  advanced  than  she  imagines.  It  is 
the  physician's  first  care  to  determine  this  point,  and  to  do  it  he 
must  make  an  examination.  This  the  patient  fully  expects  and 
will  in  no  way  object  to,  but  it  must  be  done  in  a  manner  as 
little  revolting  to  her  feelings  as  possible.    After  a  few  indifferent 


LABOR.  327 

remarks  in  a  quiet  tone  to  the  patient;  a  few  questions  in  regard 
to  the  time  the  pains  first  came  on,  their  duration,  character,  and 
situation,  and  the  intervals  of  time  between  them  ;  after  feehng 
the  pulse,  perhaps,  and  looking  at  the  tongue,  and  assuring  her 
that  her  general  condition  is  very  good  indeed,  the  nurse  is  in- 
formed that  the  patient  is  to  be  prepared  for  abdominal  palpation. 
While  the  nurse  is  arranging  the  patient  on  her  back  with  a 
single  layer  of  some  thin  material,  as  a  bed-sheet,  spread  smoothly 
over  the  abdomen,  the  physician  himself  either  leaves  the  room 
or  turns  his  back  upon  the  bed  while  he  dons  a  surgical  gown 
and  gives  his  hands  a  preliminary  washing. 

This  whole  subject  of  the  obstetric  examination  is  so  im- 
portant that  space  may  well  be  devoted  to  its  consideration. 

Abdominal  palpation  is  described  fully  in  the  chapter  upon 
The  Mechanism  of  Labor.  It  is,  therefore,  only  necessary  to 
state  here  that,  after  determining  the  position  of  the  fetus 
in  utero,  and  investigating  its  condition  by  listening  to  the 
heart-sounds,  the  nurse  is  directed  to  place  the  patient  upon 
that  side  toward  which  the  fetal  back  is  directed  and  to  prepare 
her  for  a  vaginal  examination.  For  this  purpose  the  parturient 
w^oman  is  placed  upon  her  side,  with  the  hips  brought  well 
to  the  edge  of  the  bed,  the  thighs  flexed  upon  the  abdomen, 
the  legs  upon  the  thighs.  The  clothing  is  rolled  up  above  the 
waist,  or  so  arranged  that  it  shall  not  interfere  with  the  access  of 
the  examining  hand,  and  the  bed-sheet  is  draped  over  the  patient 
so  that  a  wide  margin  of  it  falls  over  the  side  of  the  bed.  While 
this  is  attended  to  the  physician  is  cleansing  his  hands  by  a 
method  described  in  the  chapter  on  Aseptic  Technic  (p.  778). 
In  addition  to  the  hand  disinfection,  it  should  be  an  invariable 
rule  to  wear  rubber  gloves  that  have  been  boiled,  steamed,  or 
soaked  in  a  i :  1000  sublimate  solution. 

The  physician  uses  the  hand  for  the  internal  examination 
next  the  patient,  as  he  takes  a  seat  beside  the  bed,  facing  her 
genitalia.  Everything  being  in  readiness  for  the  vaginal  ex- 
amination, the  examining  finger  is  dipped  into  a  jar  of  car- 
bolated  vaselin,  or  the  unguent  is  squeezed  upon  it  from  a  col- 
lapsible tube;  the  nurse  Hfts  up  the  sheet  covering  the  buttocks, 
the  obstetrician  raises  the  upper  buttock  with  his  free  hand, 
wipes  off  the  vulvar  orifice  with  pledgets  of  cotton  soaked  in  a 
1 :  2000  sublimate  solution,  and  by  the  sense  of  sight  inserts  the 
forefinger  of  the  examining  hand  directly  into  the  gaping  vaginal 
orifice.  Nothing  is  more  foolish  than  the  ancient  practice  of  grop- 
ing about  under  a  sheet  for  the  woman's  genitalia,  thus  dangerously 
soiling  the  examining  hand  which  had  been  made  sterile  by  a  pains- 


328  LABOR  AND  THE  PUERPERIUM. 

taking  disinfection,  only  to  be  infected  again  before  its  insertion 
into  the  vagina.  The  abihty  to  derive  easily  all  the  desired  infor- 
mation from  a  vaginal  examination  only  comes  from  practice  and 
an  education  of  the  tactile  sense.  It  would  be  well,  therefore,  for 
the  practitioner,  in  the  beginning  of  his  obstetric  experience,  to 
bear  in  mind  a  series  of  questions  in  their  natural  sequence, 
which  he  desires  to  have  answered,  and  to  persist  in  his  earlier 
cases  until  repeated  and  long-continued  examinations  have  satis- 
fied his  mind.  Thus  :  the  character  of  the  vaginal  discharge  ;  the 
state  of  the  perineum,  whether  relaxed,  rigid,  or  torn  perhaps 
from  a  previous  labor ;  the  rigidity  and  distensibility  of  the 
vaginal  walls  and  the  quantity  of  secretion  upon  them, — nature's 
lubricant ;  the  capacity  of  the  pelvis  ;  the  condition  of  the  cervix, 
whether  it  is  rigid  or  yielding,  thickened,  edematous,  or  thinned 
out ;  the  degree  of  dilatation  of  the  os  ;  the  portion  of  the  fetal 
ellipse  which  is  presenting  itself  at  the  os  ;  the  engagement  of 
the  presenting  part  in  the  ■  pelvis  ;  the  position  that  the  present- 
ing part  may  have  assumed  ;  the  rupture  or  the  integrity  of  the 
membranes  ;  and,  if  the  examination  continues  during  a  pain, 
the  effect  of  the  expulsive  forces  upon  the  fetal  mass.  All  these 
are  questions  of  great  importance  in  their  bearing  upon  the  diag- 
nosis of  the  woman's  present  condition  and  upon  the  prognosis 
as  to  the  character,  duration,  and  termination  of  the  labor. 

Having  satisfied  his  mind  upon  all  these  points,  the  obstetri- 
cian enters  upon  the  management  of  labor. 

The  very  first  step  in  the  treatment  of  the  first  stage  of  labor 
should  be  the  evacuation  of  the  rectum.  The  capacity  of  a  nor- 
mal pelvis  is  none  too  great  to  permit  the  passage  of  the  fetal 
body  ;  but  if  the  pelvic  canal  is  occupied  by  a  distended  rectum 
full  of  feces,  labor  may  be  delayed,  the  woman's  suffering  is 
materially  increased,  and  the  danger  of  a  tear  in  the  greatly  dis- 
tended vagina  is  considerably  augmented.  It  is  only  the  rectum 
and  sigmoid  flexure  that  need  be  emptied,  and  this  result  is  best 
secured  by  an  enema  of  a  pint  of  soapsuds  with  a  teaspoonful 
of  turpentine  in  it.  A  well-trained  nurse  will  already  have 
done  this,  perhaps  before  the  doctor's  arrival,  if  she  thinks  that 
labor  has  really  begun.  The  enema  acts  quickly  and  effectually, 
whereas  a  purgative  administered  at  the  beginning  of  labor,  as 
has  been  recommended  by  some  obstetricians,  begins  its  action 
possibly  when  the  os  is  too  much  dilated  to  allow  the  woman  to 
use  a  commode.  The  lower  bowel  being  emptied,  the  woman,  with 
advantage  and  comfort  to  herself,  ma}'  be  allowed  to  walk  about 
the  room  or  to  sit  up  in  a  chair,  the  ph}'sician  making  an  ex- 
amination from  time  to  time  to  determine  the  progress  of  labor 
and   to  avoid   the  serious  accident  of  a  precipitate   delivery   in 


LABOR.  329 

the  erect  posture,  an  accident  dangerous  to  the  mother  and 
usually  fatal  to  the  child.  This  statement  leads  to  the  inquiry 
how  often  and  how  long  to  examine  a  parturient  woman  in  the 
first  stage  of  labor,  and  how  long  she  should  be  allowed  to  re- 
main out  of  bed  in  a  standing  or  a  sitting  posture.  In  a  normal 
case  during  the  first  stage  of  labor,  the  intervals  between  the 
examinations  are  from  two  to  four  hours,  or  even  longer.  But 
two  or  three  examinations  need  be  made  during  the  whole  labor. 
As  to  the  time  for  putting  a  woman  in  labor  to  bed  and  keep- 
ing her  there,  it  is  usual  to  lay  down  the  rule  that  as  soon  as 
the  OS  has  reached  the  size  of  a  silver  dollar  the  woman  should 
be  confined  to  bed.  Many  patients  might  be  allowed  to  be  up 
longer  than  this,  while  others  with  a  history  of,  or  conditions 
predisposing  to,  quick  labors  must  be  put  to  bed  earlier. 

Many  patients  express  a  desire  to  go  to  the  water-closet  at 
about  this  time,  but  their  request  can  on  no  account  be  allowed. 
Many  a  woman  has  discharged  her  infant  into  the  seat  of  a 
water-closet  or  into  the  well  of  a  privy,  either  by  design  or 
under  the  impression  that  she  was  having  an  evacuation  of  the 
bowels.  1 

Before  the  woman  is  put  to  bed  it  should  be  arranged  for 
the  labor  in  the  manner  illustrated  in  figure  216,  The  mattress 
is  protected  by  a  mackintosh  and  the  bed-sheet  is  guarded  by  a 
pad  of  nursery  cloth. 

As  the  first  stage  of  labor  advances,  the  suffering  of  the  woman 
increases  with  each  succeeding  pain.  The  alleviation  of  this  pain 
is  naturally  demanded  by  the  patient.  The  dangers  and  disad- 
vantages that,  it  is  claimed,  result  from  the  use  of  anesthetics  in 
labor  are:  a  prolongation  of  the  process  by  weakening  the  uterine 
contractions  and  increasing  the  intervals  betw^een  them;  a  dis- 
position to  postpartum  hemorrhage;  an  increased  hability  to  sepsis 

1  The  resident  physician  on  my  service  at  the  Howard  Hospital  was  called  to  a 
house  in  the  neighborhood,  and  fished  out  of  the  privy-well,  twelve  feet  deep,  an  infant 
which  had  been  immersed  in  the  contents  of  the  well  up  to  its  neck  for  eight  hours. 
The  mother  had  deliberately  sat  upon  the  seat  until  her  baby  dropped  from  her.  She 
had  then  thrown  three  bricks  down  upon  it.  In  spite  of  these  disadvantages  the  child 
was  extracted  alive,  by  means  of  a  pole  and  some  twine.  It  was  received  into  my 
wards  at  the  Philadelphia  Hospital,  where  it  thrived.  On  another  occasion  one  of 
the  patients  in  the  University  Maternity  locked  herself  in  the  water-closet,  dropped 
her  baby  down  the  bowl,  and  turned  on  the  water.  A  nurse's  attention  was  at 
length  attracted  to  a  stream  of  water  running  across  the  floor  of  the  corridor.  The 
water-closet  door  was  broken  open,  the  woman  pulled  off  the  seat,  and  the  child, 
whose  head  accurately  stopped  up  the  exit-pipe  of  the  bowl,  was  extracted  alive, 
thougli  it  had  been  under  water  probably  five  minutes.  One  of  my  patients,  in  the 
winter  of  1907,  with  a  permit  to  enter  the  University  Hospital,  was  coming  to  Phila- 
delphia on  the  New  York  express.  Between  North  and  West  Philadeljjhia,  the 
train  running  at  least  40  miles  an  hour,  the  woman  dropped  her  fetus  through  the 
water-closet  to  the  tracks  below.  It  was  found  more  than  an  hour  later  by  a  track- 
walker lying  alive  and  uninjured  on  the  snow.  All  cases  of  this  kind  do  not  end  so 
fortunatelv. 


330 


LABOR  AND    THE    PUERPERIUM. 


after  labor  by  a  relaxation  of  the  uterine  muscle,  and  a  subinvolu- 
tion of  the  uterus.  These  objections  are  ill-founded  if  the  anes- 
thetic is  administered  in  a  proper  manner.  An  anesthetic,  if 
not  pushed  too  far,  has  no  influence  on  the  power,  duration,  or 
frequency  of  the  pains.  By  reHeving  suffering  that  causes  ex- 
haustion   the    danger    of    postpartum    hemorrhage    is    avoided. 


Fig.  216. — Bed  arranged  for  child-birth.  The  mattress  is  protected  by  a  mackin- 
tosh, over  which  a  clean  sheet  is  spread.  The  upper  bed-clothes  are  rolled  up  at  the 
foot  of  the  bed.  The  woman's  buttocks  rest  upon  a  square  yard  of  nursery  cloth. 
The  chair  is  for  the  obstetrician  ;  at  his  feet  is  a  waste-bucket,  into  which  the  pledgets 
of  cotton  used  to  clean  the  anus  are  thrown.  The  table,  in  easy  reach,  has  upon  it 
a  large  basin  of  sublimate  solution,  i  :  2000,  in  which  are  many  large  pledgets  of  cot- 
ton ;  a  small  tin  cup  on  an  alcohol  lamp  to  boil  the  scissors  for  the  cord ;  a  half  dozen 
clean  towels  ;  a  pot  of  carbolated  vaselin  ;  a  tumbler  of  boric-acid  solution  with 
squares  of  clean  soft  linen  in  it  for  the  child's  eyes  and  mouth ;  a  tube  of  sterile  silk 
for  the  cord. 


Subinvolution  is  never  seen  as  a  result  of  anesthesia,  unless  it  is 
pushed  too  far.  In  some  women  labor  is  little  more  than  an 
inconvenience  or  a  discomfort,  and  by  no  means  an  agony. 
Women  have  been  known  to  expel  a  full-term  child  when  they  were 
hardly  conscious  that  labor  had  begun.^  To  resort,  therefore,  to 
an  anesthetic  when  there  is  no  suffering  is  obviously  absurd. 
Granting,  however,  that  in  many  cases  anesthesia  in  labor  is  an 

iDr.  B.  B.  Gates,  of  Knoxville,  tells  me  of  a  case  in  which  there  was  no  pain 
whatever  during  labor,  but  at  every  uterine  contraction  the  patient  said  she  felt  as 
though  she  bad  a  croquet  ball  in  her  mouth  (globus  hystericus). 


LABOR.  331 

advantage,  if  not  a  necessity,  the  physician  must  select  the  an- 
esthetic, and  must  determine  when  and  how  he  shall  use  it.  The 
choice  Hes  between  ether  and  chloroform.  Cocain,  it  was  thought 
at  one  time,  would  be  an  efhcient  local  anesthetic,  but  it  proved 
a  failure.  Belladonna,  apphed  locally  to  the  cervix,  is  also  useless, 
although  it  diminishes  rigidity;  the  same  may  be  said  of  chloral, 
taken  internally.  Repeated  hypodermatic  injections  of  hydro- 
bromate  of  hyoscin,  gr.  yi-g-  (scopolamin),  and  morphin,  gr.  \,  are 
sometimes  useful,  but  do  not  compare  in  efhciency  with  ether  or 
chloroform.^  After  a  personal  trial  of  this  anesthetic  I  have  given 
it  up.  There  is  a  tendency  to  prolongation  of  labor,  to  postpartum 
hemorrhage,  and  to  asphyxia  of  the  infant  if  the  woman  is  brought 
deeply  enough  under  its  influence  to  reUeve  her  pain.  Morphin 
alone  is  occasionally  indicated,  but  it  usually  delays  labor.  Spinal 
anesthesia  by  the  injection  of  cocain  solution  into  the  lumbar 
spine,  while  enthusiastically  tried  for  a  time,  deserves  no  con- 
sideration in  the  management  of  an  ordinary  case.^  The  propo- 
sition of  Stoeckel  ^  to  utilize  Cathelin's  procedure  is  more  reason- 
able. A  solution  of  novocain  0.15,  suprarenin  0.000325  in  33  c.c. 
normal  salt  solution,  is  injected  in  the  sacral  canal  through  the 
sacral  hiatus  at  the  end  of  the  bone.  The  method  is  receiving 
a  trial  in  the  University  maternity.  The  choice  in  the  east- 
ern seaboard  of  the  United  States  will  usually  be  ether.  Chloro- 
form is  in  disfavor  in  this  part  of  the  world,  although,  perhaps, 
unjustly.  Ether  is  an  efficient,  convenient,  and  satisfactory 
agent  in  obstetrical  practice,  except,  of  course,  in  the  treatment 
of  eclampsia.  There  are,  however,  two  precautions  to  be  ob- 
served in  its  administration — not  to  give  it  too  long  and  not  to 
give  too  much  of  it.  The  first  error  is  avoided  by  beginning  its 
administration  as  late  in  labor  as  possible;  it  is  better  to  put  off 
the  resort  to  an  anesthetic  until  the  second  stage  of  labor,  when 
the  suffering  in  the  first  stage  is  not  too  great.  One  avoids  giving 
too  much:  (i)  By  using  a  light  towel  thrown  over  the  face  and 
dropping  only  a  few  drops  at  a  time,  just  below  the  tip  of  the  nose, 
at  the  end  of  an  expiration,  so  that  the  whole  vapor  is  sucked  into 
the  lungs  with  the  succeeding  inspiration;  (2)  by  only  beginning 

1  "  Schmerzverminderung  und  Narkose  in  der  Geburtshiilfe  mit  spezieller  Eeriick- 
sichtigung  der  Kombinierten  Skopolamin  Morphium  Anoesthesie,"  Steinbiichel, 
Leipzic  u.  Wien,  1903.  Franklin  S.  Newell,  "  Anesthesia  in  tlie  First  Stage  of 
Labor,"  "Jour,  of  Surg.,  Gyn.,  and  Obstet.,"  July,  1906.  Gauss,  Hocheisen,  and 
Lehman  report  tlieir  results  in  670 cases.  "Med.  Klinik."  No.  6,  1906.  "  Muench. 
Med.  Woclienschr.,"   No.  37,   1906.      "  Ztsch.  f.  Geb.  u.  (]yn.,"  Bd.  Iviii,  p.  297. 

^"Medullary  Narcosis,"  W.  L.  Rodman,  "Therapeutic  Gazette,"'  Jan.  15,  1901; 
good  description  of  technique  "  Transactions  of  Soutliern  Surgical  and  Gynecol.  Assoc, 
for  1900,"  "  Year- Book  of  Medicine  and  Surgery,'  1901-1902,  "La  Presse  Medi- 
cale,'  Nov.  9,  1901,  No.  9. 

^  Zentralbl.  f.  Gyn.,  No.  i,  1909. 


332  LABOR  AND    THE   PUERPEEIUM. 

the  administration  of  ether  as  the  pains  come  on,  and  discontinu- 
ing it  between  them;  and  (3)  by  endeavoring  to  produce  not 
complete  anesthesia,  but  only  analgesia. 

As  labor  advances  and  the  first  stage  is  about  to  pass  into 
the  second,  one  should  expect  the  rupture  of  the  membranes  and 
the  escape  of  liquor  amnii.  Provision  must  be  made  for  the  sudden 
escape,  often  rather  startling  to  the  patient  or  to  an  inexperienced 
practitioner,  of  a  pint  or  more  of  liquor  amnii,  which  must  be  caught 
in  some  clean  towels  or  mopped  up  by  sterile  absorbent  cotton. 

If  the  membranes  fail  to  rupture  at  the  end  of  the  first  or  at 
the  beginning  of  the  second  stage  of  labor,  the  physician  must 
consider  whether  he  shall  artificially  break  the  bag  of  waters.  In 
the  case  of  a  primipara  such  interference  is  not  justifiable.  The 
bag  of  waters  is  a  perfect  hydrostatic  dilator,  acting  without 
great  fierce,  and  in  primiparas  a  slow,  gradual,  and  conservative 
dilatation  of  the  maternal  soft  parts  is  most  desirable,  to  avoid 
lacerations  of  the  cervix,  vagina,  or  perineum.  In  multiparae 
the  artificial  rupture  of  the  membranes  is  admissible  after  the 
completion  of  the  first  stage  of  labor;  the  interference  certainly 
hastens  the  expulsion  of  the  child,  and  as  the  soft  parts  of  a 
woman  who  has  already  borne  children  are  distensible  there  is 
not  the  same  necessity  for  care  to  preserve  nature's  conservative 
dilator.  Under  no  circumstances,  in  an  ordinary  uncomplicated 
labor,  should  the  membranes  be  ruptured  before  the  full  dilata- 
tion of  the  OS.  Any  one  who  has  observed  what  in  the  nurse's 
parlance  is  called  a  dry  labor — that  is,  one  in  which  the  mem- 
branes rupture  early — will  not  dispute  this  assertion.  Occasion- 
ally, even  in  primiparae,  the  first  intimation  that  a  woman  receives 
of  the  beginning  labor  is  the  escape  of  the  liquor  amnii,  the  mem- 
branes having  ruptured  before  the  os  is  at  all  dilated.  In  these 
cases  the  labor  is  longer,  the  woman's  suffering  is  much  greater, 
and  the  likelihood  of  damage  to  the  maternal  tissues  is  very  con- 
siderably increased.  If  the  membranes  are  artificially  ruptured 
during  the  second  stage  of  labor  in  a  multipara,  the  following  rules 
must  be  observed :  In  the  first  place,  the  membranes  are  not  to  be 
ruptured  during  a  pain,  for  the  sudden  gush  of  liquor  amnii  might 
carry  with  it  a  loop  of  the  cord.  It  must  be  clearly  established 
that  the  tissues  to  be  punctured  are  the  membranes,  and  not 
the  child's  scalp  or  the  distended  lower  uterine  segment.  It 
is  often  possible  to  hook  the  finger-tip  into  a  fold  of  the  mem- 
branes and  to  tear  them  by  pulling  outward.  They  may  also  be 
pinched  through  between  the  forefinger  and  the  thumb  or  middle 
finger.  If  these  manual  methods  do  not  succeed,  the  Emmet 
curette  forceps  may  be  used  to  pinch  and  tear  a  fold  of  the  mem- 
branes. 


LABOR.  333 

During  the  second  stage  of  labor  a  new  and  important  element 
enters  into  its  mechanism — the  powerful  action  of  the  abdominal 
walls.  Indeed,  it  has  been  claimed  that  the  contraction  of  the 
abdominal  muscles  is  the  principal,  the  uterine  force  the  secondary, 
expulsive  power  in  this  stage  of  labor.  By  the  employment 
of  a  "puller"  which  fixes  the  chest  above  and  the  pelvis  below, 
the  power  of  the  abdominal  muscles  may  be  utilized  to  its  utmost 
extent.  This  is  done  by  fixing  the  feet,  protected  by  a  pillow, 
against  the  foot-board  of  the  bed,  and  attaching  to  one  corner 
of  it  a  rope  or  a  twisted  sheet  on  which  the  woman  can  pull  with 
her  hands. 

The  straining  accompanying  the  uterine  action,  denoting 
that  the  second  stage  of  labor  has  begun  and  that  the  presenting 
part  is  descending  into  the  birth-canal,  lasts  in  the  typically 
normal  case  about  an  hour  and  a  half  or  two  hours,  when,  if  the 
physician  observes  the  genitalia, — and  the  period  of  labor  has 
arrived  when  it  is  desirable  actually  to  observe  the  process, — he 
notices  that  the  anus  is  opened  and  the  rectal  mucous  membrane 
is  exposed  to  view  ;  with  every  pain  small  masses  of  feces  are 
extruded  from  the  anus  which  must  be  wiped  away  always 
toward  the  coccyx  with  large  pledgets  of  cotton  soaked  in  sub- 
limate solution  ;  the  perineum  bulges  outward,  and  the  vulvar 
orifice  opens  a  little,  disclosing  a  small  portion  of  the  child's 
scalp.  With  every  pain  the  perineum  becomes  more  distended, 
the  vulva  gapes  more  widely,  until,  finally,  the  perineum,  by  the 
tremendous  tension  to  which  it  is  subjected,  becomes  almost 
as  thin  as  paper,  and  it  seems  a  physical  impossibility  for  the 
head  to  escape  through  the  vulva  without  tearing  the  over- 
stretched tissues  that  form  the  pelvic  floor.  In  fact,  frequently 
the  fetal  head  does  make  a  way  for  itself  through  the  perineum, 
instead  of  over  and  in  front  of  it  as  nature  intended,  and  after 
labor  there  is  found  a  more  or  less  extensive  laceration  of  the 
pelvic  floor.  Schroeder's  statistics  show  that  in  primiparae  the 
fourchet,  the  little  fold  of  skin  at  the  posterior  commissure  of 
the  vulva,  is  torn  through  in  6i  per  cent.,  while  in  34  per  cent, 
of  all  primiparae  and  in  9  per  cent,  of  multiparae  the  peri- 
neum is  more  or  less  lacerated.  If  the  patient  is  placed  upon  an 
examining  or  operating  table  a  few  days  after  labor  and  a  careful 
examination  is  made  of  the  genital  canal,  the  proportion  of  lacera- 
tions in  the  anterior  and  posterior  vaginal  walls  involving  the 
underlying  muscle  will  be  found  at  least  twice  as  great  as  Schroe- 
der's statistics  indicate.  The  problem  presents  itself,  therefore, 
to  every  obstetrician  in  every  case  to  avoid  these  accidents  if 
possible.  Although  the  management  of  a  perfectly  normal  labor 
is  here  considered,  so  frequent  an  accident  is  laceration  of  the 


334  LABOR  AND  THE  PUERPERIUM. 

birth  canal,  and  so  constant  is  the  danger  of  it,  that  it  is  necessary 
to  take  up,  in  this  connection,  the  study  of  its  causes,  in  order 
to  devise  an  effective  preventive  treatment.  The  causes 
of  laceration  of  the  pelvic  floor  may  be  divided  under  three 
heads:  (i)  A  relative  disproportion  in  size  between  the 
outlet  of  the  birth- canal  and  any  part  of  the  fetus,  which 
makes  the  escape  of  the  latter  a  physical  impossibility  unless 
the  aperture  is  enlarged  by  tearing  its  least  resisting  border ; 
(2)  such  a  rapid  expulsion  of  any  part  of  the  fetal  body  that 
the  maternal  tissues  can  not  gradually  dilate,  but  give  way 
before  the  sudden  strain  imposed  on  them  ;  and  (3)  any  abnor- 
mality in  the  mechanism  of  labor  which  pushes  the  present- 
ing part  backward  against  the  center  of  the  perineum  and 
prevents  its  propulsion  forward  under  the  symphysis  pubis.  In 
the  first  category,  relative  disproportion,  might  be  put  those 
cases  in  which  the  head  is  too  large  or  the  vulva  too  small ; 
and,  further,  those  cases  in  which  the  head  presents  its  largest 
instead  of  its  smallest  diameters,  as  happens  in  insufficient  flexion 
in  vertex  presentations.  Under  the  second  heading,  precipitate 
expulsion,  might  be  put  all  cases  in  which  the  expulsive  forces 
are  too  strong  ;  cases  of  straight  sacrum,  in  which  the  fetal  head 
is  shot  through  the  pelvic  canal  and  suddenly  puts  great  strain 
on  the  perineum  ;  cases  in  which  too  powerful  traction  is  made 
with  the  forceps.  Under  the  third  head,  an  abnormal  backward 
direction  of  the  presenting  part,  might  be  placed  those  cases  in 
which  a  pelvis  of  a  male  type,  with  approximated  pubic  rami, 
,  pushes  the  head  backward  and  throws  a  greater  strain  on  the 
perineum  ;  cases  again,  in  which  the  woman,  just  as  the  head  is 
passing  through  the  vulva,  suddenly  straightens  her  legs  and 
brings  them  close  together ;  further,  cases  in  which  a  straight 
sacrum  allows  the  head  to  descend  directly  upon  the  perineum 
instead  of  directing  it  forward  toward  the  vulvar  opening,  as  a 
normally  curved  sacrum  should  do  ;  and,  finally,  cases  in  which 
overflexion  brings  the  vertex  to  bear  directly  upon  the  center  of 
the  perineum. 

It  must  appear,  from  these  many  different  causes,  that  the 
preventive  treatment  of  laceration  of  the  perineum  differs  con- 
siderably in  order  to  meet  the  diverse  conditions  that  threaten 
the  integrity  of  the  pelvic  floor ;  thus,  if  there  is  a  very  great 
relative  disproportion  between  the  head  and  the  vulva  and  the 
opening  must  be  artificially  enlarged,  instead  of  allowing  the 
perineum  to  tear,  perhaps  into  the  rectum,  it  is  better  to  nick  the 
margin  of  the  vulva  on  the  side,  and  allow  the  tear  to  occur 
where  it  can  not  extend  too  far,  and  can  do  no  harm.  This 
simple  operation  is   called  episiotoviy.      It  should   be   distinctly 


LABOR.  335 

understood  that  it  is  called  for  only  in  rare  and  exceptional 
cases.  Personally,  I  have  no  confidence  in  it  whatever,  as  I 
believe  it  to  be  based  upon  an  incorrect  idea  as  to  the  mechanism 
of  pelvic  tears.  After  the  delivery  of  the  child  and  the  placenta 
the  small  wound  is  to  be  closed  by  catgut  or  silkworm-gut 
sutures.  If  the  danger  to  the  perineum  comes  from  a  precipitate 
expulsion  of  the  head,  the  proper  preventive  treatment  is  a 
retardation  of  labor,  either  by  holding  the  advancing  head  back 
with  the  hand  or  with  the  forceps,  or  by  giving  an  anesthetic  to 
control  the  voluntary  muscles.  Faulty  mechanism,  as  over- 
flexion  or  extension,  may  be  corrected  by  the  forceps.  It  is 
evident,  therefore,  that  no  single  plan  of  preventive  treatment, 
no  inflexible  method  of  "supporting  the  perineum,"  as  it  is 
called,  will  avail  in  all  cases. 

There  is,  however,  a  routine  practice  directed  against  the 
commonest  cause  of  "lacerated  perineum"  that  may  prevent  a 
laceration,  or  at  least  a  very  extensive  tear  extending  into  the 
rectum.  There  are  excuses  for  the  lesser  grades  of  laceration, 
and  it  is  true  that  no  physician,  be  his  skill  what  it  may, 
can  absolutely  avoid  this  accident;  but  a  complete  destruction  of 
the  perineum,  a  tear  through  the  rectum,  is  rarely  justifiable.  It 
is  most  frequently  the  result  of  some  blunder,  carelessness,  or 
error  of  technic. 

As  the  head  distends  the  vulva  almost  to  the  utmost,  it  fails 
to  recede  as  it  has  done  after  the  previous  pain,  but  remains  in 
view  until  the  next  uterine  contraction,  which,  with  the  abdominal 
contraction  that  accompanies  it,  suddenly  expels  the  head  through 
the  widely  stretched  external  outlet.  The  expulsive  force  acting 
suddenly  and  being  much  greater  than  is  necessary  to  overcome 
the  slight  resistance  now  offered  by  the  soft  parts,  lacerates 
the  tissues  instead  of  dilating  and  stretching  them.  This  being  the 
most  frequent  cause  of  lacerated  perineum,  it  is  easy  to  devise  a 
means  to  meet  and  overcome  the  difficulty.  The  main  requirement 
is  to  regulate  the  expulsive  force  so  that  it  is  just  sufficient  to  over- 
come the  slight  resistance  offered  by  the  distended  perineum,  and 
as  an  auxiliary  measure  to  restrain  the  progress  of  the  head 
should  this  force  become  too  great  or  be  exerted  too  suddenly. 
It  is  obvious  that  one  can  not  govern  the  force  of  the  uterine 
contractions,  which  are  involuntary  ;  but  one  can  regulate  the 
force  and  duration  of  the  abdominal  contractions  by  appealing 
to  the  woman's  will.  Thus,  the  physician  can  call  upon  her  to 
strain  forcibly  or  gently,  as  the  case  may  require,  bringing 
into  more  or  less  active  play  the  expulsive  action  of  the  abdom- 
inal walls  ;  he  can  command  her  to  stop  straining,  or  to  open 
her  mouth  and  breathe  rapidly,  which  amounts  to  the  same  thing, 


33^  •  LABOR  AND    THE  PUERPERIUM. 

thus  inhibiting  the  greater  part  of  the  expulsive  force;  or,  if  a 
powerful  uterine  contraction  should  come  on,  or  if  the  woman, 
should  exert  her  voluntary  muscles  too  violently,  or  should  fail 
to  obey  the  command  to  stop  straining,  the  expulsive  forces 
may  be  neutralized  simply  by  making  such  firm  pressure  against 
the  child's  head  with  the  hand  that  it  will  not  budge.  At  the 
same  time  the  outspread  hand,  which  can  most  conveniently  be 
used  for  the  purpose,  is  applied  to  the  distended  perineum  so 
that  the  thumb  and  forefinger  encircle  the  posterior  commissure 
of  the  vulva.  This  hand  helps  to  flex  the  head  when  the 
occiput  is  anterior  ;  it  restrains  the  progress  of  the  head,  and  it 
pushes  it  forward  under  the  arch  of  the  pubes,  away  from  the 
overstretched  muscles  of  the  pelvic  floor.  This  is  the  best 
plan  of  supporting  the  perineum,  as  it  is  called,  though  it  is 
not  really  a  support  of  the  perineum-  at  all,  but  a  diminution 
of  the  expulsive  forces  and  a  regulation  of  the  progress  of 
the  fetal  head,  which  is  supported,  restrained,  and  directed  by 
pressure,  partly  through  the  perineum,  partly  directly  upon 
the   head   itself^ 

Presuming  that  these  precautions  have  been  successful,  that 
the  perineum  has  been  safely  retracted  over  the  child's  head, 
and  that  the  head  is  born,  the  face  at  first  appears  white,  but 
almost  immediately  turns  quite  purple  and  looks  as  if  the  child 
must  be  choking  to  death.  It  is,  as  a  rule,  however,  in  no  seri- 
ous danger.  The  head  being  the  only  part  of  the  fetal  body  free 
from  pressure  the  blood  is  determined  to  it,  and  is  prevented  from 
returning  freely  by  the  pressure  about  the  neck,  thus  giving 
the  child's  head,  as  it  protrudes  from  the  vagina,  a  most  alarm- 
ing appearance  of  deep  asphyxia.  There  is,  however,  in  some 
cases,  a  more  serious  element  in  the  asphyxiated  look  of  the 
child ;  in  one  out  of  four  labors  the  cord  is  found  coiled  about 
the  child's  neck,  usually  only  once,  and  that  lightly,  but  occa- 
sionally many  times,  nine  coils  having  been  recorded  in  one 
case,  and  so  tightly  occasionally  as  to  completely  strangulate  the 
infant,  not  by  pressure  upon  the  neck,  but  upon  the  cord.  This 
anomaly  occurring  so  frequently,  and  having  such  serious  results, 
must  always  be  borne  in  mind,  and  as  soon  as  the  head  is  born 
and  the  neck  becomes  accessible  the  medical  attendant  must  at 
once  ascertain  whether  the  cord  encircles  it  or  not,  by  sweeping 
a  forefinger  between  the  child's  neck  and  the  maternal  symphysis. 

If  the  cord  is  found  in   this  situation,  it  should  be  gently 

1  Sarwey  in  "Winckel's  Handbuch"  (vol.  i^,  1904)  gives  some  fifteen  different 
methods  of  supporting  the  perineum.  There  is  no  one  of  them  that  insures  the 
woman  against  injury.  The  plan  advocated  by  the  author  is  a  modified  Ritgen 
manoeuvre,  the  physician  seated  alongside  the  bed  facing  the  vi'oman's  vulva,  and  the 
patient  lying  upon  her  side. 


LABOR. 


337 


pulled  upon,  and  whichever  portion  yields  should  be  drawn  out, 
so  enlarging  the  loop  that  it  may  be  slipped  over  the  head; 
or,  if  that  is  impossible,  making  the  loop  at  least  large,  enough 


/ 


.<- 


N^J 


■y 


^< 


Fig.  217. — Retarding  the  escape  of  the  head  and  pushing  it  away  from  the  peri- 
neum. The  patient  is  on  her  left  side.  The  physician  sits  alongside  the  edge  of  the 
bed,  facing  the  vulva.     The  woman's  knees  are  held  apart  by  a  pillow  between  them. 

to  allow  the  shoulders  to  pass  through  ;  or  if  that,  again,  is  not 
feasible,  if  the  cord  so  firmly  constricts  tire  child's  neck  that  the 
loop  or  loops  can  not  be  loosened,  it  may  be  hastily  ligatured 
with  a  double  thread  and  then  cut  between  the  ligatures.  The 
child,  in  such  a  case,  must,  of  course,  be  extracted  immediately, 
else  it  will  be  fatally  asphyxiated. 

The  cord  not  being  felt,  or  having  been  attended  to,  if  found 
around  the  neck,  the  physician  next  turns  his  attention  to  the 
child's  head.  The  head  is  protruding  from  the  vulva,  the  face 
is  swollen  and  almost  purple,  looking  as  if  the  only  hope  for  the 
fetus  lay  in  speedy  delivery  ;  the  labor  is  almost  concluded,  the 
medical  attendant  sees  his  anxiety  and  attendance  ahuost  at  an 
end,  and  for  all  these  reasons,  especially  if  he  is  inexperi- 
enced, he  feels  strongly  impelled  to  terminate  a  process  that 
seems  to  endanger  the  fetus,  that  has  caused  his  patient  much 
suffering,  and  himself,  perhaps,  fatigue,  by  pulling  on  the  head 
and  rapidly  extracting  the  fetal  body.  If  he  does  so,  however, 
the    shoulders    hastily    pulled    through    the    vulva  will   almost 


338  LABOR  AND   THE  PUERPERIUM. 

surely  lacerate  the  perineum,  perhaps  deeply.  Many  a  case  of 
lacerated  perineum,  even  into  the  rectum,  is  explained  in  this 
way.  A  still  more  serious  consideration  is  that  immoderate 
traction  upon  the  head  may  seriously  injure  the  child's  spine  and 
the  spinal  column.  As  experience  has  shown  that  the  fetus  is 
not  subjected  to  great  danger  in  this  situation,  and  as  premature 
eiTorts  to  extract  it  entail  upon  both  woman  and  child  a  danger 
more  imminent  than  that  which  it  is  endeavored  to  avert,  it  is 
better  to  do  nothing  at  this  stage  of  labor  but  simply  to  support 
the  head  upon  the  hand,  waiting  for  the  action  of  the  natural 
expulsive  forces,  which  will  rotate  the  shoulders,  and  with  them 
the  head,  and  shortly  after  expel  the  rest  of  the  body.  While 
the  child's  head  protrudes  from  the  vulva  the  opportunity  should 
be  taken  to  cleanse  the  eyelids  with  squares  of  clean  soft  linen, 
soaked  in  boric  acid  solution,  gr.  x  to  fsj  of  distilled  water,  and 
to  inject  this  solution  into  the  eyes  with  a  pipet.  After  waiting 
a  minute  or  two,  the  physician  may  stimulate  the  uterus  by  rub- 
bing or  kneading  it,  and  may  assist  its  contractions  by  pressure 
upon  the  abdominal  walls  over  the  fundus.  This  is  all  the  as- 
sistance required  in  a  normal  case.  With  this  sHght  addition 
to  the  natural  forces  the  shoulders  descend  and  rotate;  the  ante- 
rior shoulder  slips  out  first  under  the  symphysis  pubis,  the  pos- 
terior shoulder  and  arm  quickly  follow,  the  anterior  arm  then 
emerges,  and,  the  shoulders  being  born,  the  rest  of  the  body  is 
immediately  expelled  so  rapidly  that  it  is  difficult  to  follow  the 
mechanism.  It  is  admissible,  if  one  is  careful  not  to  use  too  much 
force,  to  pull  the  child's  head  backward  to  facilitate  the  birth  of 
the  anterior  shoulder,  forward  to  assist  the  birth  of  the  posterior 
shoulder  (Figs.  218  and  219).  Indeed,  it  is  an  advantage  to  do 
so,  if  traction  is  not  made  too  soon  or  too  forcibly.  The  moment 
the  child  escapes  from  the  birth-canal  it  emits  a  lusty  cry,  which 
is  usually  synchronous  with  a  sigh  of  intense  satisfaction  from 
the  mother,  who  has  in  an  instant  been  entirely  relieved  of  long 
and  intense  suffering.  There  are  now  two  patients  on  the  physi- 
cian's hands  at  once,  and,  although  he  must  in  practice  devote  his 
attention  to  both  equally  and  at  the  same  time,  it  is  more  conve- 
nient here  to  consider  their  management  separately.  Although 
the  child's  expulsion  from  the  mother  gives  her  such  immense 
relief,  it  by  no  means  terminates  the  labor  nor  brings  her  an 
immunity  from  all  danger ;  indeed,  the  chief,  the  most  common 
danger  of  parturition,  hemorrhage,  may  be  said  to  begin  with 
the  expulsion  of  the  child,  and  sometimes  a  most  difficult  and 
dangerous  complication  of  labor,  adhesion  of  the  placenta  to  the 
uterine  wall,  only  manifests  itself  after  the  complete  escape  of  the 
child  from  the  birth-canal.  There  are,  therefore,  two  problems 
with  which  to  deal  in  the  third  stage  of  labor  in  almost  every 


LABOR. 


339 


case,  no  matter  how  normal  it  may  appear, — the  dehvery  of  the 
placenta  and  the  prevention  of  hemorrhage.  As  hemorrhage  may 
occur  before  the  expulsion  of  the  placenta,  and  therefore  stands 
first  in  point  of  time;  as  this  accident  is  of  the  gravest  nature  and 
its  prevention  of  the  greatest  importance,  the  first  thought  of  the 


Fig.  2l8. — Pulling  the  infant's  head  toward  the  maternal  sacrum  to  facilitate  the 
escape  of  the  anterior  slioulder  (Bumm). 


medical  attendant  should  be  the  routine  means  to  adopt  in  every 
case  to  prevent  its  occurrence. 

Provided  the  uterus  contracts  and  remains  contracted,  the 
enormous  blood-vessels  in  its  walls  are  obliterated  and  hemor- 
rhage is  impossible.  On  the  other  hand,  if  the  uterus  remains 
flaccid  and  uncontracted  while  the  placenta  is  being  separated, 
or  if  the  organ,  at  first  contracted,  afterward  relaxes,  hemorrhage 
of  the  most  alarming  character  must  as  necessarily  occur. 


340 


LABOR   AND    THE  PUERPERIUM. 


The  whole  problem,  therefore,  of  preventing  hemorrhage 
after  delivery  resolves  itself  into  a  problem  of  securing  and  of 
maintaining  uterine  contraction. 

Firm  Contraction  of  the  Uterus  After  Labor  is  Secured  by  Ex- 
ternal and  by  Internal  Stimuli  to  Contraction. — The  internal 
stimulus  consists  of  a  dram  dose  of  the  fluid  extract  of  ergot  in  a 
little  water,  administered  as  soon  as  the  child's  body  is  born.  It 
has  been  claimed  that  ergot  should  never  be  administered  before 


Fig.  219. — Pulling  the  infant's  head  toward  the  maternal  symphysis  to  extract  the 
posterior  shoulder  ( Bumm) . 


the  expulsion  of  the  placenta  for  fear  of  hour-glass  contraction  of 
the  uterus.  But  it  requires  at  least  fifteen  minutes  after  ergot 
is  administered  by  the  mouth  before  its  action  is  felt  by  the  uterus; 
meanwhile,  in  a  normal  case  the  placenta  is  expressed  and  the  in- 
fluence of  the  ergot  is  felt  at  the  time  it  is  most  needed,  as  a  rule, 
just  after  the  conclusion  of  the  third  stage  of  labor.  The  external 
stimulus  consists  of  manipulation  of  the  uterus.  Luckily  the  uter- 
ine muscle  is  irritable,  and  shows  its  irritation  by  contracting  its 
fibers.  Luckily,  again,  it  is  accessible.  One  can  easily  grasp 
it  through  the  abdominal  walls  ;  can  rub  it  and  exert  direct 
pressure  upon  it,  these  actions  exercising  a  powerful  irritant  in- 
fluence upon  the  uterus  and  bringing  about,  in  the  ordinary  case, 


LABOR.  341 

firm  contraction.  This  is  the  most  efficient,  readily  appHed  ex- 
ternal stimulus  to  uterine  contraction,  and  one  that  must  be  in- 
variably applied,  and  that,  too,  continuously  from  the  moment  the 
infant's  body  is  expelled  until  a  milder  form  of  external  stimulus 
which  is  to  maintain  uterine  contraction  is  adjusted, — the  obstet- 
rical binder.  The  moment  that  the  child  escapes  from  the  woman's 
body  the  physician  or  nurse  seizes  the  uterus  through  the  ab- 
dominal wall  and  exerts  constant  pressure  upon  it,  irritating  it 
still  more  from  time  to  time  by  a  kneading  or  a  rubbing  motion. 
If  the  woman  is  fortunate  enough  to  have  a  good  nurse,  this 
duty  may  safely  be  left  to  her,  while  the  doctor  washes  his  hands 
and  takes  a  brief  rest.  Some  fifteen  minutes  having  elapsed,  the 
placenta  being  delivered,  the  woman  having  been  cleaned  and 
made  more  comfortable,  the  constant  pressing  and  kneading  of 
the  uterus  may  be  replaced  by  the  more  gentle  and  more  continu- 
ous external  stimulus  of  the  hinder  and  abdominal  pad.  The 
binder  holds  an  important  place  in  the  treatment  of  Enghsh- 
speaking  women.  In  some  civilized  countries  it  is  not  used  at  all, 
and,  it  must  be  confessed,  it  is  unnecessary,  from  the  medical  point 
of  view,  after  the  first  twenty-four  hours. 

The  obstetrical  binder,  however,  adds  greatly  to  the  woman's 
comfort  by  maintaining  the  intra-abdominal  pressure  and  thus 
preventing  cerebral  anemia.  It  undoubtedly  preserves  the  figure, 
— a  fact  to  which  no  woman  is  indifferent, — it  diminishes  the  risk 
of  permanent  diastasis  of  the  recti  muscles,^  and  it  lessens  the 
danger  of  postpartum  hemorrhage  by  maintaining  a  tonic  con- 
traction of  the  uterus.  For  all  these  reasons  the  use  of  the  ob- 
stetrical binder  is  well  justified — is,  in  fact,  demanded — in  the 
intelligent  management  of  the  puerpera.  The  best  binder  is  a 
piece  of  unbleached  muslin,  about  a  yard  and  a  quarter  long  and 
wide  enough  to  reach  from  the  trochanters  to  the  floating  ribs. 
It  is  pinned  together  from  above  downward,  and  is  made  to  fit 
more  snugly  and  comfortably  by  making  gores  at  the  sides  above 
and  below  the  hips.  The  pad  should  consist  of  one  or  two  folded 
towels  put  above  the  navel  to  fill  the  hollow  in  the  epigastrium 
left  by  the  evacuation  of  the  womb  and  its  reduction  in  size. 

The  second  problem  of  the  two  that  confront  a  physician  in 
the  management  of  the  woman  in  the  last  stage  of  labor  is  the 
delivery  of  the  placenta.  To  superintend  this  process  intelli- 
gently it  is  necessary  to  recall  the  chief  phenomena  of  the  mech- 
anism of  the  third  stage  of  labor. 

The  placental  structure  resembles  a  sponge,  and  as  the  uterine 

1  For  a  period  of  about  six  months  I  omitted  the  binder  at  tlie  re(|uest  of  Dr.  Stan- 
ton, who  was  studying  blood-]iressure  in  tlie  jiuerpem?  of  the  University  Hospital. 
During  that  winter  I  was  obliged  to  operate  on  more  cases  of  diastasis  of  the  recti 
muscles  than  I  would  normally  do  in  two  or  three  years. 


342 


LABOR  AND  THE  PUERPERIUM. 


wall  contracts  and  retracts,  the  placenta  follows  the  reduction  in 
the  size  of  the  placental  site  by  a  corresponding  reduction  in  the 
-placental  area,  up  to  a  certain  point.  The  placenta  diminishes  in 
size  until  all  its  villi  come  in  actual  contact  with  one  another; 
until,  instead  of  being  a  spongy  organ  with  the  intervillous  blood- 
spaces  separating  the  villi  from  one  another,  the  whole  organ 

becomes    a    solid    mass,    and     can 

j : >^=^:::r '  not  accompany  a  further  reduction 

in  the  area  of  uterine  wall  to  which 
it  is  attached,  so  that  the  smallest 
additional  contraction  of  the  uterine 
muscle  must  spring  off  the  whole 
placental  mass  at  once.  This  point 
is  reached  when  the  placenta  has 
been  reduced  to  about  one-half  of  its 
natural  area — a  fact  that  has  been 
demonstrated  in  uteri  removed  by 
the  Porro  Cesarean  section  or  in 
postmortem  examinations  of  patients 
who  had  died  during  or  directly  after 
labor.  The  expulsion  of  the  placenta 
after  its  detachment  is  easily  under- 
stood ;  lying  in  the  uterine  cavity  as 
a  loose  foreign  body,  all  that  is  re- 
quired is  the  vigorous  action  of  the 
uterine  muscle  to  drive  it  out.  But, 
once  beyond  the  province  of  the 
thick,  muscular  portion  of  the  uterus, 
above  the  contraction- ring,  there  is 
no  further  force  to  expel  the  placenta, 
for  it  lies  in  the  semiparalyzed  lower 
uterine  segment  (see  Fig.  220),  cer^dx 
or  vagina,  where  it  may  remain  for 
hours  or  days,  until  it  undergoes  de- 
composition/ As  the  lower  animals 
never  require  an  artificial  delivery  of 
the  after-birth,  many  obstetricians  of 
the  eighteenth  century  argued  that 
the  delivery  of  the  placenta  should  be  left  entirely  to  nature.  The 
result  was  disastrous,  as  may  be  imagined. 

It  is,  therefore,  a  necessary  part  of  the  management  of  the 
third  stage  of  labor  to  secure  the  separation  of  the  placenta  by 
stimulating  the   uterus   to   contract   and   by  aiding   it   to  expel 

1  V.  Campe  ("Zeit.  f.  Geburtsh.  u.  Gyn.,"  Bd.  x,  H.  2)  in  120  observations 
found  that  in  24  instances  the  placenta  had  not  been  expelled  in  twelve  hours. 


Fig.    220. — Dilated    lower 

uterine  segment  and  cervix  after 
labor,  from  a  frozen  section 
(Benckiser  and  Hofmeier). 


LABOR. 


343 


its  contents  by  exaggerating  its  expulsive  power.  These  two 
objects  are  best  obtained  by  what  is  known  as  Crede's  method, 
a  method  first  proposed  to  the  profession  in  a  systematic  m.anner 
by  the  late  Professor  Crede,  of  Leipsic/  in  1861.  A  similar  plan 
had  been  in  use  in  Dublin  for  a  long  time  before,  and  many 
primitive  and  savage  people  have  employed,  perhaps  for  ages, 
methods  based  upon  the  same  principle. 


Fig.  221. — The  expression  of  the  placenta. 


Fig.  222. — The  reception  of  the  placenta  in  a  basin. 


In  applying  Crede's  method  the  uterus  is  seized  in  a  grasp 
illustrated  in  figure  311,  is  kneaded  and  rubbed  until  it  con- 
tracts with  vigor;  only  then,  and  only  in  conjunction  with  the 
uterine  contraction,  should  it  be  firmly  pressed  down  in  the 
direction  of  the  axis  of  the  pelvic  inlet,  while  it  is  compressed 

1  "  Monats.  f,  Geburtskunde,"  xvii,  p.  274. 


344  LABOR  AND  THE  PUERPERIUM. 

between  the  fingers  and  thumb  with  considerable  force.  The 
placenta  is  squeezed  out  as  the  stone  is  pressed  out  of  a  cherry. 
It  should  be  expressed  twelve  or  fifteen  minutes  after  the  child 
is  born,  as  complete  separation  has  not  occurred  in  the  average 
case  till  this  time  has  elapsed.  As  it  slowly  emerges  from  the  vulva 
it  should  be  caught  in  the  obstetrician's  hand,  while  a  nurse  holds 
a  basin  pressed  close  into  the  mother's  lower  buttock,  to  receive  the 
blood  that  usually  spurts  out  with  the  after-birth.  The  mem- 
branes trail  after  the  placenta,  running  up  into  the  vagina  and 
the  uterine  cavity.  To  extract  them  without  tearing  them,  and 
thus  leaving  a  portion  behind,  they  should  be  seized  between  the 
whole  length  of  the  thumb  and  forefinger  and  gently  pulled,  first 
forward  toward  the  symphysis,  then  backward  toward  the  sacrum, 
the  uterus  meanwhile  being  allowed  to  relax.  It  is  a  mistake  to 
turn  the  placenta  over  several  times  to  make  a  "  rope  "  of  the 
membranes. 

To  return  to  the  infant.  The  head  and  shoulders  having 
escaped,  the  rest  of  the  body  slips  out  almost  immediately,  the 
child's  arrival  being  announced  usually  by  a  vigorous  cry,  a  purely 
reflex  action  caused  by.  the  sudden  shock  which  the  new-born 
experiences  on  suddenly  emerging  from  an  aquatic  existence,  in 
which  its  immediate  surroundings  have  a  temperature  of  about 
99°,  into  the  atmosphere  and  a  temperature  not  over  70°.  This 
violent  shock  produces  not  only  a  spasmodic  action  of  the  diaph- 
ragm and  the  muscles  of  respiration,  but  also  of  the  bladder, 
and  of  all  of  the  muscles  of  the  body  as  well,  so  that  often  urine 
is  voided  directly  after  birth,  and  the  arms  and  legs  are  moved 
about  quite  violently.  As  soon  as  the  child  is  born,  it  is  well  to 
see  that  its  air-passages  are  clear  and  not  clogged  by  mucus  or 
blood  that  might  have  been  inspired  during  labor.  This  is  done 
by  crooking  the  little  finger  and  introducing  it  back  of  the  epiglottis; 
if,  however,  the  child  at  once  emits  a  vigorous  cry,  it  is  proof 
enough  that  the  respiratory  tract  is  not  obstructed.  The  infant 
is  then  placed  on  its  right  side,  this  posture  favoring  the  closure  of 
the  foramen  ovale  and  facilitating  the  passage  of  the  blood  from 
the  ascending  cava  over  the  Eustachian  valve  into  the  right  auricle. 
The  position  should  also  be  so  arranged  as  to  turn  the  child's  face 
from  the  mother's  genitals  and  to  protect  the  infant's  air-passages 
from  the  maternal  discharges  incident  to  the  third  stage  of  labor, 
care  being  taken,  also,  not  to  put  the  cord  too  much  on  the 
stretch,  for  all  this  time,  of  course,  the  infant  remains  attached 
to  the  mother  by  the  umbilical  cord.  Now  arises  the  question, 
in  every  case,  as  to  the  advisability  of  severing  the  cord  at  once 
and  getting  the  child  out  of  the  way.  The  placenta,  it  has  been 
argued,  no  longer  performs  its  vital  functions  ;  the  child  breathes. 


LABOR. 


345 


and,  therefore,  it  might  be  better  to  cut  the  cord,  to  remove  the 
infant  from  the  bed,  and  to  turn  it  over  to  the  nurse.  This  plan, 
however,  does  not  take  into  account  the  fact  that  there  remains 
a  considerable  quantity  of  fetal  blood  in  the  placenta  ;  that  it  is 
an  advantage  to  have  all  of  this  blood,  if  possible,  returned  to 
the  infantile  body  where  it  belongs,  and  that,  further,  the  deple- 
tion of  the  placenta  renders  its  expulsion  easier.  The  blood  in 
the  placenta  will  return  to  the  child's  body,^if  time  is  allowed 
for  it  ;  on  the  one  hand,  the  action  of  the  respiratory  muscle 
exerts  a  suction  upon  the  placental  vessels,  which  aspirates  the 
blood  from  the  placenta  ;  on  the  other  hand,  the  pressure  upon 
the  placenta  by  the  uterus  drives  the  placental  blood  into  the 
fetal  body.  To  demonstrate  the  advantage  of  late  ligation  of 
the  cord,  Budin  ^  conducted  a  series  of  experiments,  with  the 
following  results  :  the  cord  ceased    beating  in   22  cases,  on  the 


Fig.  223. — The  posilion  in  which  the  child  should  be  placed  after  birth. 

average,  in  two  and  one-half  minutes.  In  these  cases  the  average 
weight  of  the  placenta  was  520  gm.  {\\  lb.),  and  the  amount  of 
blood  that  escaped  from  the  umbilical  vein  in  20  cases  was  92  gm. 
(3.2  oz.  Avoir.)  less  in  late  than  after  immediate  section  of  the  cord. 
Thus,  by  immediate  ligation  92  gm.  (3.2  oz.  Avoir.)  of  blood 
are  lost  to  the  infant's  body.  Moreover,  in  contrasting  the  weights 
of  children  after  immediate  and  late  ligation  of  the  cord  there  was  a 
gain  of  two  to  three  ounces  in  favor  of  late  ligation.  It  is  better, 
therefore,  to  wait  two  or  three  minutes  after  the  birth  of  the  infant 
before  cutting  its  cord.^  The  proper  time  having  arrived,  the  cord 
should  be  ligated  about  two   fingers'   breadth  from  the  child's 

1  Publications  du  "Progr^s  M6dical,"  1876;  also  "  Obstetrique  et  Gynecologie," 
1886. 

2  There  has  been  some  criticism  of  Budin's  proposition  to  ligate  the  cord  late; 
several  German  authors  have  attributed  a  number  of  infantile  complications  to  it,  but 
the  objections  to  the  plan  are  ill  founded. 


346  LABOR  AND  THE  PUERPERIUM. 

body  with  a  piece  of  stout  surgeon's  silk  or  narrow  bobbin,  steril- 
ized. The  ligature  is  tied  firmly  once  around  with  a  double  knot. 
The  ends  are  then  doubled  around  again  and  are  tied  with  a  single 
and  a  bow  knot,  so  that  the  nurse,  after  the  child  is  washed,  may 
slip  this  last  knot  and  may  then  retie  the  ligature  firmly.  This 
precaution  surely  avoids  a  primary  or  secondary  hemorrhage 
from  the  cord,  which  sometimes  occurs  in  consequence  of  a  shrink- 
age of  the  mucous  tissue,  making  the  original  ligature  too  loose. 
The  obstetrician  is  now  ready  to  cut  the  cord.  The  child  is 
slippery  and  hard  to  hold;  its  legs  and  arms  are  jerked  about  in  a 
very  disconcerting  manner  to  the  beginner,  so  that  carelessness 
in  the  use  of  scissors  at  this  juncture  might  result  in  injury  to  the 


Fig.  224. — Cutting  the  cord. 

fingers,  the  toes,  or,  in  the  male  child,  to  the  penis.  The  manner  of 
cutting  the  cord  illustrated  in  figure  224  surely  avoids  all  such 
accidents.  The  child's  connection  with  its  mother  being  severed, 
it  is  wrapped  in  a  blanket  ready  to  receive  it  and  is  put  in  some 
safe  place,  where  it  will  not  be  trodden  nor  sat  upon.  Its  own 
crib  is  the  best  place  for  it.  The  cut  end  of  the  cord  attached  to 
the  placenta  is  not  tied,  but  is  allowed  to  drain  into  a  basin,  so  as 
to  lessen  as  much  as  possible  the  bulk  of  the  placenta.  In  case 
of  twins,  however,  a  double  ligature  on  the  cord  is  required,  else 
the  second  child  might  bleed  to  death  on  account  of  anastomosis 
between  the  vessels  of  the  placenta. 


THE  PUERPERAL  STATE.  347 

CHAPTER  II. 
The  Puerperal  State. 

The  moment  that  labor  terminates  with  the  expulsion  of  the 
placenta,  there  begins  an  effort  on  the  part  of  nature  to  restore 
to  their  normal  condition  the  organs  and  systems  that  have 
been  in  an  active  state  of  development  for  nine  months  before  ; 
there  is  destroyed  in  a  few  weeks  what  it  has  taken  months 
to  build  up,  and  with  this  destructive  process  goes  on  with 
equal  rapidity  one  of  growth  and  repair.  There  is  a  reduc- 
tion of  the  sexual,  the  circulator\%  and  the  nervous  systems 
to  their  normal  capacities  and  functions  by  the  destruction  of 
redundant  material ;  at  the  same  time  there  is  a  repair  of  the 
injuries  of  child-birth,  the  formation  of  a  new  endometrium,  and 
the  rapid  development  of  an  entirely  new  and  complicated  func- 
tion, lactation.  And  yet,  by  a  provision  of  nature  which  is  almost 
beyond  comprehension,  these  two  opposed  processes  of  decay 
and  regeneration  go  on  at  the  same  time  in  one  body,  involving 
whole  systems  and  organs,  without  manifesting  themselves  in 
the  slightest  derangement  of  the  individual's  health.  Under  no 
other  circumstances  could  an  organ  weighing  two  pounds,  and  as 
large  as  the  liver,  degenerate  and  in  great  part  disappear  without 
the  gravest  symptoms  of  constitutional  disorder.  In  no  other 
condition  could  the  whole  composition  of  the  blood  be  materially 
altered  ;  the  heart  changed  in  size,  power,  and  capacity ;  the 
nervous  system  modified  in  sensibility ;  a  large  body-cavity, 
stripped  of  its  mucous  membrane  and  again  resupplied  with  a 
new  lining ;  large  organs,  as  the  breasts,  suddenly  assuming 
great  functional  activity,  without  very  marked  evidence  of  dis- 
ease ;  and  yet  in  the  puerperal  state  there  are  all  these  remarkable 
changes  while  the  woman  in  appetite,  feeling,  and  temperature  is 
in  perfect  health.  But  it  is  obvious  that  in  a  condition  which, 
though  it  is  called  physiological,  borders  so  closely  on  the  patho- 
logical, very  little  is  required  to  pass  the  boundary-line  into  dis- 
ease. Anomalies  of  excess  and  deficiency  in  the  natural  processes 
are  common  ;  the  raw  surface  of  the  uterus  with  the  wounds  of 
the  vagina  and  vulva  give  ready  entrance  to  infectious  bacteria 
and  their  toxins,  and  the  whole  individual  seems  especially  sen- 
sitive to  unfavorable  external  influences,  both  mental  and  j)hysical. 
Consequently  this  is  the  period  in  the  history  of  the  child-bearing 
woman  that  is  most  beset  with  difficulties  and  dangers  and  most 
likely  to  be  marked  by  accidents  and  complications.     The  pre- 


348  LABOR  AND  THE  PUERPERIUM. 

ventive  and  curative  treatment  of  these  complications  is  one  of 
the  most  difficult  tasks  in  obstetrics,  and  success  here,  as  else- 
where in  medicine,  depends  to  a  great  extent  upon  a  thorough 
knowledge  of  the  natural  processes. 

The  puerperal  state,  or  the  puerperium,  comprises  the  time 
from  the  termination  of  labor  until  the  uterus  has  regained  its 
natural  size.      This  is  a  period,  in  the  normal  case,  of  six  weeks.  ^ 

The  study  of  the  physiological  phenomena  in  the  puerperium, 
or  puerperal  state,  involves  a  study  of  the  reduction  of  the  uterus 
directly  after  delivery  to  the  uterus  of  the  healthy  non-pregnant 
woman, — a  process  called  technically  "  the  involution  of  the 
uterus  "  ;  it  involves  a  study  of  the  involution  of  the  vagina,  of 
the  destruction  of  the  deciduous  mucous  membrane,  and  the 
regeneration  of  the  endometrium  ;  of  the  retrograde  changes  that 
occur  in  the  uterine  ligaments  and  peritoneal  covering  and  in  the 
ovaries  ;  of  the  alterations  by  which  the  blood  and  the  heart 
regain  their  normal  condition  and  of  the  changes  in  the  pulse  ;  of 
the  changes  in  the  body-weight,  the  temperature,  the  skin  ;  the 
action  of  the  bladder  and  of  the  alimentary  canal.  An  important 
factor  also  in  the  puerperium  is  the  establishment  of  the  milk 
secretion. 

The  Involution  of  the  Uterus. — Three  theories  have  been 
advanced  to  account  for  it  :  (i)  A  fatty  degeneration  of  the 
muscle-fibers  and  the  absorption  of  the  fine  granular  fat -globules 
to  the  complete  destruction  of  the  uterine  muscle,  its  place  being 
taken  by  a  new  growth  of  muscle-fibers  developed  from  the 
embryonal  muscle-cells  in  the  outer  layers  of  the  myometrium. 
(2)  A  partial  degeneration  and  an  atrophy  of  the  large  muscle- 
fibers  seen  in  a  pregnant  uterus  at  term.  (3)  The  conversion  of 
the  muscle-cell  contents  into  a  peptone,  its  absorption  into  the 
blood-current  and  discharge  through  the  kidneys,  giving  rise  to 
the  peptonuria  of  puerperal  women  (Fischel). 

Kilian,^  in  his  examination  of  rabbits'  uteri  thirty  to  thirty- 
six  hours  after  they  had  expelled  their  young,  found  fat-globules 
in  the  epithelial  covering  of  the  uterus,  noticed  that  the  muscle- 
fibers  looked  fainter  and  paler  than  in  pregnancy,  and  saw  in 
their  interior  very  fine,  shining  fat-globules;  alongside  of  these 
degenerated  muscle-fibers  Kilian  found  some  quite  young  fibers, 
as  he  had  seen  them   in  the  uteri  of  young  animals.      Heschl  ^ 

1  The   word    puerperium    comes  from  piier,  a  child,   and  pario,   to  bear,   and 
denoted,  in  the  original   Latin,  the  child-bed  period,  the  lying-in  period  ;   so  it  is  an  . 
appropriate  term  to  designate  this  one  of  the  four  periods  in  obstetrics, — pregnancy, 
labor,  the  puerperium,  and  lactation. 

2  "  Die  Structur  des  Uterus  bei  Thieren,"  Henle  u.  Pfeuffer's  "  Zeits.  f.  ration- 
elle  Medicin,"  1849  u.  1850,  Bd.  viii,  u.  ix. 

3  "  Untersuchungen  uber  das  Verhalten  des  menschlichen  Uterus  nach  der 
Geburt.,"  "  Zeits.  der  k.  k.  Gesellschaft  der  Aerzte  in  Wien,"  1852,  viii,  2. 


THE  PUERPERAL  STATE. 


349 


confirmed  Kilian's  observations,  and  went  even  further  in  de- 
claring that  the  muscle-cells  were  completely  destroyed  by  fatty 
degeneration  ;  this  writer  saw,  in  the  outer  portion  of  the  uterine 
body,  at  first  nuclei ;  which,  developing  cell-contents  around 
them,  gradually  transformed  themselves  into  typical  unstriped 
muscle-fibers.  Thus,  after  labor  the  uterine  muscle  was  destroyed 
and  a  new  development  of  muscle-tissue  occurred  to  take  its 
place.     Robin  i  claimed  that  the  involution  of  the  uterine  muscle 


Fig.  225. — a,  Uterine  muscle-fibers  nine  days  postpartum ;  b,  uterine  muscle- 
fibers  eight  days  postpartum ;  c,  uterine  muscle-fibers  in  the  eighth  month  of 
pregnancy. 


is  essentially  an  atrophy  of  the  individual  muscle-cells.  Kolliker  ^ 
says  that  the  involution  of  the  puerperal  uterus  consists  of  a 
diminution  in  the  size  of  the  contractile  fibers  in  the  muscle- 
layer  and  a  fatty  degeneration.  Mayor, -^  from  a  study  of  fourteen 
specimens  dating  from  the  first  day  after  delivery  until  the  ninth 

1  "Diet,  encycl.  des  Sc.  med.,"  2e  serie,  t.  x,  p.  14. 

2  "  Gewebelehre,"  5.  Aufl.,  p.  565. 

3  '   Etude  histologique  sur  1' Involution  uterine,"  "Archives  de  Physiol,  norm,  et 
path.,"  ix,  X,  1887,  p.  560. 


350  LABOR  AND  THE  PUERPERIUM. 

month  of  lactation,  concludes  that  the  fatty  degeneration  of  the 
muscle-fibers  is  more  pronounced  than  Robin  thought,  but 
not  as  complete  as  Heschl  believed  ;  it  does  not  seem  to  cause 
the  destruction  of  the  muscular  elements.  Mayor,  therefore, 
attributes  to  atrophy  the  chief  role  in  the  involution  of 
the  uterus.  Winckel  ^  holds  that  the  reduction  of  the  puerperal 
uterus  is  due  to  fatty  degeneration.  Sanger,  ^  from  the  observa- 
tion of  twelve  uteri  obtained  from  four  hours  to  fifty-five  days 
after  labor,  recognizes  the  fatt}'  degeneration  in  the  muscle- 
cells,  but  does  not  believe  that  they  are  destroyed.^  Micro- 
scopic sections  of  five  uteri  in  my  possession,  obtained  respec- 
tively in  the  last  week  of  pregnancy,  two  hours,  thirty-six  hours, 
seventy-two  hours,  and  seven  days  after  labor,  indicate  that 
fatty  degeneration  plays  a  most  important  part  in  the  reduction 
of  the  large  muscle-cells  characteristic  of  pregnancy  to  the  much 


|^'^S5;?SrS3]^nT-==S^  '%i\^«i''7r5r:^^^^iCfem^?r^^ 


Fig.  226. — Muscular  tissue  of  the  pregnant  and  of  the  puerperal  uterus. 

smaller  muscular  fibers  of  the  unimpregnated  uterus.  My  own 
belief  is  that  the  redundant  material  within  each  cell  is  destroyed 
by  some  degenerative  process  (chiefly  fatty),  but  that  the  cell  is  not 
destroyed  in  toto.  Measurements  made  by  Sanger  ^  show  plainly 
that  the  reduction  of  the  uterus  after  labor  is  effected  by  a  diminu- 
tion in  the  size  of  the  individual  fibers,  and  not  by  their  destruction.^ 

1  "LehrbuQh  der  Geburtshiilfe,"   1889. 

2  Abst.  in  Schmidt's  "  Jahrbiicher,"  No.  3,  1888,  p.  250. 

3  Sanger  says  that  "  the  fat-globules  and  other  degeneration  products  do  not  enter, 
as  such,  into  the  circulation,  but  are  oxidized  on  the  spot.  There  is  no  such  thing  as 
a  puerperal  lipemia"  ("Die  Riickbildung  der  Muscularis  der  puerperalen  Uterus"). 

■*  Loc.  cit. 

^  Fiber-length  in  pregnant  uterus 208.7 /i. 

"          "      in  first  few  hours  postpartum 158. 3 /i. 

'<          "      until  the  fourth  day  postpartum II7-4/"- 

"          "  in  first  half  of  second  week  postpartum  .    ...  82.7^. 

"          "  in  beginning  of  third  week  postpartum.    .    .    .  32.7 /i. 

"          "      at  end  of  fifth  week  postpartum 24.4 /z. 


THE  PUERPERAL  STATE. 


351 


The  shrinkage  of  the  uterus  in  the  process  of  involution  is  ex- 
pressed by  the  following  average  measurements:  Height  of  fundus 
above  symphysis,  directly  after  labor,  10.9  cm.;  on  the  first  day 
the  fundus  rises  to  13.5  cm.;  on  the  eighth  day  it  has  sunk  to  7.3 
cm.  The  breadth  of  the  fundus  at  the  tubal  insertions  is  1 1  cm. 
directly  after  labor;  12.2  cm.  on  the  first  day;  8.1  cm.  on  the 
eighth  day.  The  uterine  cavity  measures  14.8  cm.  on  the  first 
day;  10  cm.  by  the  fourteenth  day. 


Fig.  227. — Lochia  on  the  second 
day  (lochia  cruenta),  showing  a  few 
cocci  and  streptococci  :  a,  Decidual 
cells ;  b,  red  blood-corpuscles ;  c, 
white  blood- corpuscles  ;  d,  epithelium 
(Winckel). 


Fig.  228. —  Lochia  on  the  fourth 
day:  a,  Decidual  cells  ;  iJ,  white  blood- 
corpuscles  ;  c,  a  few  red  blood-corpus- 
cles ;  (/,  epithelium  ;  e,  micro-organisms 
(Winckel). 


Fig.  229. — Lochia  on  seventh  day  ;  afebrile  case:  a.  Blood-corpuscles  ;  b,  diplo- 
cocci  and  monococci ;  c,  white  blood-corpuscles ;  d,  epithelium  ;  e,  decidual  cells 
(Winckel). 

There  is  a  greater  unanimity  of  opinion  in  regard  to  the  invo- 
lution of  the  serous  covering,  connective  tissue,  blood-vessels,  and 
mucous  membrane  of  the  puerperal  uterus. 

Mayor  ^  found,  in  the  peritoneal  covering  of  the  uterus  after 
delivery,  a  number  of  folds  in  the  membrane;  at  the  bottom  of 
these  folds  the  endothelial  cells  seemed  to  be  transformed  into  a 
spherical  shape.     KiUan^  found  the   cells   in    this   region   infil- 

1  Loc.  cit.  2  Loc.  cit. 


352  LABOR  AND  THE  PUERPERIUM. 

trated  with  fat-globules.  Bernstein^  in  a  study  of  involution  in 
the  rabbit's  uterus,  paid  especial  attention  to  the  behavior  of  the 
connective  tissue.  He  found  that  the  reduction  of  this  tissue  in 
the  puerperal  uterus  Mras  effected  by  a  fatty  degeneration  of  the 
connective-tissue  cells,  and  by  a  drying  out,  as  it  were,  of  the 
connective-tissue  iibers;  these,  deprived  of  the  excessive  blood- 
supply  of  pregnancy,  dry  up  and  shrink.  Bernstein  incidentally 
mentions  the  fatty  degeneration  of  the  peritoneal  endotheUum, 
and  expresses  the  opinion  that  the  muscle-cells,  while  they  do 
undergo  a  fatty  degeneration,  are  not  completely  destroyed. 

The  chief  changes  in  the  blood-vessels  seem  to  be  shrinkage, 
the  obliteration  of  many  large  vessels  by  a  connective-tissue 
growth  in  the  intima,  associated  with  fatty  degeneration  of  the 
media,^  and  the  development  in  the  adventitia  of  the  vessels  not 
obliterated  of  new  elastic  fibers. 

The  involution  of  the  endometrium  is  now  clearly  under- 
stood, thanks  to  the  investigations,  first,  of  Friedlander,^  then 
of  Kundrat,^  Engelmann,^  Langhans,**  Leopold,^  Wormser,^  and 
others.  When  the  ovum  is  cast  off  at  term,  it  carries  with  it,  in  the 
strictly  normal  case,  the  whole  ovular  or  epichorial  decidua  and 
the  upper  cellular  layer  of  the  uterine  decidua,  leaving  behind  on 
the  uterine  wall  the  lower  cellular  layer  and  the  glandular  por- 
tion of  the  uterine  mucous  membrane.  This  membrane,  deprived 
in  great  part  of  its  nutriment  by  the  contraction  of  the  uterine 
wall  and  the  obliteration  of  many  of  its  blood-vessels,  loses  its 
vitality  in  that  portion  furthest  removed  from  its  source  of  nutri- 
ment— the  superficial  layer  of  decidual  cells.  These  die  and  are 
cast  off  with  the  lochial  discharge  in  a  condition  of  coagulation- 
necrosis,  fatty  degeneration  or  disintegration.  By  the  shedding  of 
these  cells  the  glandular  layer  of  the  decidua  is  laid  bare.  Now 
the  involution  of  the  endometrium  ceases  and  a  regeneration  of  the 
membrane  begins.  The  epithelial  cells  within  the  glands  take 
on  an  active  growth  and  reproduction;  the  interglandular  con- 
nective tissue  shares  in  the  new  development;  by  its  growth  it 
rises  in  embankments  between  the  glands,  making  them  deeper, 
and  so  in  time  reproduces  the  characteristic  utricular  glands  of 
the  uterine  mucous  membrane.  This  process  requires  some  time. 
Mayor  says:  "On  the  twenty-fourth  day  after  dehvery  I  have 

1  "  Ein  Beitrag  zur  Lehre  von  der  puerperalen  Involution  des  Uterus,"  D.  i, 
Dorpat,  1885. 

^  Balin,  "  Ueber  das  Verlialten  der  Blutgefasse  im  Uterus  nach  stattgehabter 
Geburt,"  "Archiv  f.  Gyn.,"  Bd.  xv. 

^"Physiol.  Anatom.  Untersuchungen  iiber  den  Uterus,"  Leipsic,  1 870; 
"Archiv  f.  Gyn.,"  Bd.  ix.  ^  "Wien.  med.  Jahrbiicher,"  1873. 

5  Ibid.  8  "Archiv  f.  Gyn.,"  Bd.  viii.  '  Ibid.,  Bd.  xii. 

'  Wormser,  "Die  Regeneration  der  Uterusschleimhaut  noch  der  Geburt.," 
"  Arch.  f.  Gyn.,"  Bd.  Ixix,  H.  3  (good  recapitulation  on  p.  565). 


THE  PUERPERAL  STATE.  353 

not  found  glands  in  the  region  of  the  placental  insertion.  The 
mucous  membrane,  although  reconstructed  at  the  second  month, 
is  then  furnished  with  fewer  glands,  less  regularly  disposed,  and 
of  a  greater  caliber  than  in  the  normal  state." 

The  uterus  is  not  the  only  organ  of  the  sexual  system  that 
experiences  a  retrograde  change  after  labor.  The  ovaries  and 
tubes,  the  broad  and  round  ligaments,  the  pelvic  connective 
tissue,  blood-vessels,  and  lymphatics,  all  undergo  modification. 
That  portion  also  of  the  birth-canal — the  lower  uterine  segment, 
the  cervix,  the  vagina,  and  the  vulva — which  is  dilated  to  an 
extreme  degree  to  allow  the  passage  of  the  fetal  body,  must 
likewise  exhibit  rapid  involution  to  regain  its  wonted  tone  and 
caliber.  In  these  structures  the  process  is  mainly  one  of  retrac- 
tion of  overstretched  tissue  ;  but  there  is,  in  addition,  a  certain 
amount  of  degeneration  and  atrophy  of  the  redundant  cells  that 
the  increased  blood-supply  and  increased  stimulus  to  growth  of 
pregnancy  called  into  existence.  Particularly  is  this  true  of  the 
lower  uterine  segment  and  cervix,  which  in  their  involution  dis- 
play an  intermediate  process  between  that  by  which  the  reduc- 
tion of  the  uterine  body  is  effected  and  that  by  which  the  lower 
portion  of  the  parturient  tract   regains  its  normal  state. 

The  involution  of  the  uterine  adnexa  progresses  satisfac- 
torily if  the  uterine  involution  itself  is  normal.  The  reduction 
of  the  overstretched  vagina  and  vulva  is  sure  to  occur  if  these 
parts  have  not  been  seriously  lacerated,  although,  like  all  over- 
stretched muscular  canals,  they  never  quite  return  to  their 
original  caliber. 

From  the  large  sinuses  at  the  placental  site,  laid  bare  after 
the  separation  of  the  placenta  ;  from  the  innumerable  little  ves- 
sels of  the  decidua  that  have  been  torn  in  the  separation  of  the 
ovum  from  the  uterus  ;  from  the  rents  of  various  degrees  that 
have  been  made  in  the  cervix,  vagina,  and  vulva  during  labor,  it 
is  inevitable  that  there  should  be,  for  some  time  after  delivery, 
an  oozing  of  blood  in  considerable  quantity.  As  the  residue  of 
the  decidua  and  the  blood-clots  remaining  in  the  uterine  cavity 
are  disintegrated,  the  products  of  this  decomposition  must  also 
escape  externally.  And  as  the  whole  genital  canal,  lined  by  a 
mucous  membrane,  is  stimulated  and  irritated  b)'  foreign  sub- 
stances and  a  large  blood-supply,  it  is  obvious  that  the  mucous 
secretion  of  the  genital  tract  will  be  considerably  increased,  and 
must  make  its  escape  also  from  the  vagina.  This  composite 
discharge  after  labor,  made  up  of  blood,  degenerated  epithelial 
cells,  the  debris  of  disintegrating  animal  material,  mucus,  and 
large  numbers  of  harmless  micro-organisms,  is  called  "the 
lochia.'"     It  is  important  to  appreciate  the  normal  character  of 

'  A  word  derived  from  the  (ireek  Xo-^or,  pertaining  to  a  woman  in  child-bed. 
23 


354  LABOR  AND  THE  PUERPERIUM, 

this  discharge,  for  changes  in  its  quantity,  odor,  or  constituent 
parts  often  point  to  some  morbid  process.  The  older  writers 
on  obstetrics  paid  great  attention  to  this  feature  of  the  puerperal 
state,  and  gave  to  the  discharge  three  names,  which  indicate  the 
three  changes  that  it  undergoes  in  appearance.  For  the  first 
five  days  it  is  called  lochia  rubra ;  for  the  next  two  days,  lochia 
serosa ;  and  after  that,  lochia  alba.  At  first,  as  might  be  ex- 
pected, the  discharge  is  almost  wholly  bloody — the  lochia  rubra. 
As  the  repair  of  the  injuries  of  parturition  progresses  and  the  hem- 
orrhage ceases,  the  discharge  is  a  serous  exudation  and  a  catarrh 
of  the  mucous  lining  of  the  genital  tract — the  lochia  serosa. 
The  dead  tissue  in  the  genital  canal  is  cast  off  in  increasing  quan- 
tities as  the  involution  of  the  birth  canal  progresses  ;  disintegrated 
and  fatty  epithelial  cells  are  mixed  in  the  discharge ;  micro-organ- 
isms are  found  in  it,  while  the  pus  frorh  the  granulating  wounds 
all  along  the  genital  tract  forms  an  important  constituent  of  the 
discharge  after  the  sixth  or  seventh  day.  To  the  lochial  dis- 
charge at  this  period  is  given  the  name  lochia  alba.  The  last 
stage  of  the  lochial  discharge  lasts  from  the  seventh  until 
the  tenth,  twelfth,  or  fourteenth  day,  or  even  longer.  Two 
other  features  of  the  lochial  discharge  are  also  of  clinical  inter- 
est— the  quantity  and  the  odor.  The  amount  of  discharge  at 
the  three  different  periods  may  be  expressed  scientifically  thus  : 
During  the  first  four  days  the  amount  of  discharge  is  i  kilo- 
gram, or  2.2  pounds  ;  during  the  next  two  days,  280  grams,  or 
about  10  oz.  Avoir.;  and  until  the  ninth  day,  205  grams,  or  about 
7  oz.  Avoir.,  the  entire  loss  amounting  to  3^  pounds.  These 
figures,  however,  are  of  no  value  to  the  practical  clinician. 

No  physician  in  private  practice  can  accurately  measure  the 
amount  of  lochial  discharge  ;  so  that  the  convenient  method  of 
estimating  it  has  been  adopted  of  noting  the  number  of  napkins 
or  pads  that  are  soiled  in  the  twenty-four  hours.  The  normal 
puerpera  should  not  require  a  change  of  the  vulvar  pads  oftener 
than  six  times  in  the  twenty-four  hours  for  the  first  four  or  five 
days.  The  importance  of  being  able  to  distinguish  between  a 
normal  and  abnormal  amount  of  lochial  discharge  is  obvious. 
Otherwise  a  dangerous  hemorrhage  might  be  overlooked;  a 
diminution  or  even  suppression  of  the  lochia  might  be  unnoticed. 

The  odor  of  the  lochia  during  the  period  of  sanguinolent 
discharge  is  that  of  fresh  blood  or  raw  meat.  Later,  when  the 
mucous  secretion  forms  a  considerable  part  of  it,  the  predomi- 
nant odor  is  that  peculiar  to  the  secretion  from  these  parts. 
If  masses  of  decidua,  placenta,  membranes,  or  blood-clots  are 
retained  in  liter 0  and  saprophytes  gain  access  to  them  in  a 
situation  favorable  to  their  decomposition,  the  lochia  at  once 
takes  on  a  putrid  odor.      This  is  frequently  the  first  signal  of  a 


THE  PUERPERAL  STATE.  355 

possible  toxemia.  While  recognizing  the  value  of  a  putrid  odor  as 
a  danger-signal,  it  must  be  remembered  that  absence  of  odor  is 
possible  with  dangerous  streptococcic  or  staphylococcic  infection. 
The  involution  of  the  uterus  has  been  described  as  a  continual 
process,  moving  on  evenly  from  beginning  to  end.  But  as  it  de- 
pends primarily  upon  the  contraction  of  the  uterine  muscle-fibers  it 
is  indicated  graphically  by  a  series  of  waves,  representing  contrac- 
tions of  the  uterus  of  more  or  less  force  and  frequency  and  inter- 
missions of  less  firm  contraction  ;  the  retraction  of  the  uterine  mus- 
cle, however,  maintaining  fairly  well  what  is  gained  by  contraction. 
Each  case  has  a  certain  degree  of  individuality ;  in  one  the  con- 
tractions are  firm  and  the  intervals  between  them  short ;  in  another 
it  is  the  reverse  and  all  gradations  may  be  found  between  the 
extremes  ;  but  while  there  are  in  every  case  individual  pecu- 
liarities, the  action  of  the  uterus  after  labor  is  governed  by  a  few 
general  laws.  Directly  after  labor  there  is  a  firm  contraction  which 
reduces  the  size  of  the  uterus  in  all  directions  below  the  measure- 
ments obtained  a  few  hours  later;  then  follows  a  relaxation,  the 
fundus  rising  2  cm.  or  more  and  its  breadth  increasing  by  more 
than  a  centimeter.  Suckling  the  child  stimulates  the  contraction 
and  retraction  of  the  uterus.  If  the  child  is  not  nursed  involution 
is  slower  and  less  complete.  In  primiparae,  the  uterus  being  more 
powerful,  better  supplied  with  muscular  tissue  than  it  will  ever 
be  again  in  a  subsequent  confinement,  contracts  so  vigorously, 
relaxes  so  little,  that  after  the  expulsion  of  the  placenta  the 
uterine  cavity  is  almost  obliterated,  and  the  amount  of  bloody 
lochia  is  reduced  to  a  minimum.  On  the  other  hand,  in  mul- 
tiparae,  the  uterine  muscle  being  in  some  degree  weakened  by 
stretching  and  perhaps  by  some  destruction  of  muscle-substance 
that  has  occurred  in  previous  pregnancies,  the  uterus  after  labor 
does  not  contract  so  firmly  and  the  relaxations  between  the 
contractions  are  greater  in  degree  and  duration.  If  the  uterine 
muscle  has  been  overstretched,  as  it  is  in  plural  pregnancies 
or  in  cases  of  hydramnios,  or  if  the  labor  has  been  exceedingly 
long  or  unusually  precipitate,  very  firm  contraction  does  not  ap- 
pear after  labor  and  there  are  apt  to  occur  periods  of  over-relaxa- 
tion. This  condition,  in  civilized  women,  is  so  very  common 
that  it  is  necessary  to  study  it  under  the  head  of  the  physiology  of 
the  puerperium,  and  yet  the  consequences  of  a  failure  on  the  part 
of  the  uterine  muscles  to  contract  with  maximum  intensity  after 
labor  are  always  unpleasant,  and  may  be  disastrous.  A  relaxation 
of  the  uterine  muscle-fibers  implies  a  loosening  of  the  countless 
living  ligatures  that  bind  the  large  vessels  of  the  pueq^eral  uterus. 
The  immediate  effect  is  an  escape  of  blood  into  the  uterine  cavity. 
Oozing  out  gradually  from  the  imperfectly  closed  blood-vessels 
and  sinuses,  and,  finding  space  in  the  enlarged  uterine  cavity  to 


356  LABOR  AND  THE  PUERPERIUM. 

collect,  it  forms  clots  often  of  considerable  size,  which  act  upon 
the  uterus,  like  any  foreign  body  in  it,  as  an  irritant,  exciting 
it  to  active  contractions  which  only  cease  when  the  foreign 
substance  is  expelled.  These  active  contractions  of  the  uterus 
are  always  painful,  with  a  pain  like  that  of  a  cramp  in  any 
muscle. 

These  painful  contractions,  affecting  the  uterus  after  delivery, 
caused  primarily  by  lack  of  firm  contraction,  and  immediately  by 
the  presence  of  clots  of  blood  in  utero,  are  called,  after-pains, — 
the  painful  contractions  of  the  uterus  after  labor.  For  the  reasons 
already  given  they  are  not  experienced  by  primiparse  unless  the 
uterus  has  been  unduly  distended  or  the  labor  has  been  too  pro- 
longed or  too  precipitate.  On  the  other  hand,  they  are  a  constant 
phenomenon  in  multiparse,  and  the  phy-sician's  treatment  of  them 
constitutes  almost  always  a  part  of  his  routine  management  of  the 
puerperal  state  in  such  patients.  Apparently  a  trifling  matter,  it 
is  really  one  of  considerable  importance.  In  the  first  place,  the 
pain  is  sufficiently  distressing  to  demand  relief,  but,  more  impor- 
tant still,  these  after-pains  indicate,  to  the  educated  physician,  the 
presence  within  the  uterus  of  blood-clots  or  other  putrescible 
material;  and  until  they  are  expelled,  and  the  uterus  is  induced 
to  remain  in  a  state  of  firm  contraction,  the  woman  is  not  entirely 
safe  from  septicemia.  Moreover,  it  is  necessary  to  be  familiar 
enough  with  the  clinical  features  of  after-pains  to  be  able  to  dis- 
tinguish them  from  the  pain  of  peri-uterine  inflammation.  This 
should  not  be  difficult.  The  intermittent  character  of  after-pains; 
their  cramp-like  nature;  exacerbations  when  the  child  is  suckled; 
the  fact  that  pressure  does  not  increase  the  pain,  and  that  the  pulse 
and  temperature  are  unaffected,  suffice  to  distinguish  the  painful 
contractions  of  the  uterus  after  labor  from  the  pain  of  inflammation. 

The  appropriate  treatment  of  after-pains  is  suggested  by 
their  cause  and  nature.  It  is  the  administration  of  ergot  to 
stimulate  vigorous  contraction  and  firm  retraction  of  the  uterine 
muscle,  and  of  opium  to  diminish  the  pain  of  the  contraction.  A 
mixture  of  fluid  extract  of  ergot  and  paregoric  is  a  useful  prescrip- 
tion, though,  in  cases  of  extreme  pain,  jergot  by  the  mouth  and 
morphin  hypodennatically  give  a  better  and  quicker  result. 

Although  the  most  remarkable  changes  that  occur  in  a 
woman's  organism  after  labor  are  seen  in  the  genital  organs, 
the  whole  body  undergoes  a  modification.  The  respiratory, 
circulatory,  nervous,  and  excretory  apparatuses  are  affected,  with 
accompanying  peculiarities  of  respiration,  pulse,  temperature, 
weight,  the  excretion  of  urine  and  sweat,  and  the  evacuation  of 
the  bowels,  while  the  nervous  system  shows  a  gradual  change 
from  the  nervous  irritability  characteristic  of  pregnancy  to  the  de- 
gree of  equanimity  that  the  individual  may  have  before  possessed. 


THE  PUERPERAL  STATE.  357 

Alterations  in  the  Circulatory  Apparatus  of  the  Puerpera. 

— The  pulse  of  a  woman  during  labor  is  rather  rapid,  full,  and 
bounding  ;  directly  after  delivery  it  becomes  preternaturally  slow  ; 
if  the  individual's  normal  pulse-rate  were  70  to  80,  it  might, 
during  labor,  rise  to  90,  but  directly  afterward  it  sinks,  perhaps, 
to  60  or  even  lower.  It  is  occasionally  as  low  as  40  in  a  perfectly 
healthy  young  woman.  In  looking  for  the  cause  of  this  altera- 
tion in  pulse-rate  one  must  recall  the  influence  of  gestation 
upon  the  heart  and  the  alterations  in  the  constitution  of  the 
blood  during  pregnancy.  The  whole  volume  of  the  latter  is  in- 
creased, but  not  by  an  equal  increase  of  all  the  constituent  parts  ; 
the  corpuscles  are  relatively  decreased  in  proportion  to  the 
liquor  sanguinis  ;  the  watery  element  of  the  blood  is  propor- 
tionately increased,  making  the  condition  of  the  blood  during 
pregnancy  one  of  hydremia.  There  is  a  relative  decrease  of 
albumin,  blood-salts,  and  the  percentage  of  hemoglobin,  a  relative 
increase  of  the  fibrin-making  ferment.  Expressed  definitely,  this 
decrease  is  to  the  extent  of  about  700,000  red  blood-corpuscles 
per  cubic  millimeter  and  about  eight  per  cent,  of  hemoglobin. 
Within  the  first  twenty-four  hours  after  labor  the  decrease  in 
red  blood-corpuscles  and  hemoglobin  is  yet  more  marked,  on 
account,  no  doubt,  of  the  escape  of  blood  in  the  third  stage  of 
labor  and  immediately  after  it.  But  after  the  first  twenty-four 
hours  the  blood  begins  to  recover  its  normal  constitution,  and  at 
the  end  of  two  weeks  it  is  so  far  on  the  road  to  perfect  involution 
that  it  is  much  nearer  a  normal  condition  than  it  was  in  the  latter 
half  of  pregnancy,  although  it  is  still  somewhat  deficient  in  red 
blood-corpuscles  and  in  hemoglobin. 

The  leukocytes  decrease  rapidly  after  labor,  reaching  their 
minimum  number  twelve  hours  post-partum;  the  number  then 
increases  as  a  moderate  leukocytosis  until  lactation  is  established, 
whereupon  the  number  is  again  diminished. 

These  changes,  however,  do  not  explain  the  cause  of  a  slow 
pulse  in  the  puerperal  state:  it  is  discovered  in  the  heart. 
It  is  claimed  that  the  area  of  cardiac  dullness  is  increased 
in  pregnancy,  and  that  there  is  a  hypertrophy  of  the  walls 
of  the  left  ventricle.  As  the  whole  volume  of  blood  is  increased 
in  pregnancy,  and  as  additional  resistance  to  the  tirculation 
is  offered  by  increased  intra-abdominal  pressure  and  by  direct 
pressure  of  the  uterus  upon  the  pelvic  vessels,  it  is  reasonable 
to  assume  that  the  heart,  in  addition  to  being  hypertrophied,  is 
also  dilated.  The  additional  force  and  capacity  of  the  heart  is 
acquired  to  meet  the  additional  demands  of  pregnancy :  A 
greater  volume  of  blood  is  propelled  through  the  vessels  by  an 
enlarged  and  strengthened  heart,  beating  with  a  normal  rapidity. 
Labor  comes   on,   the   uterine   cavity  is   emptied,  and  suddenly 


358  LABOR  AND  THE  PUERPERIUM. 

the  increased  vascular  power  has  become  unnecessary  if  not 
dangerous.  The  amount  of  work  done  by  the  heart  is  repre- 
sented by  two  factors  ;  the  rapidity  plus  the  strength  of  the  beat 
and  the  power  of  the  heart  can  be  lessened  by  diminishing  either 
one  of  these  factors.  It  is  obvious  that  the  increased  power  of 
the  hypertrophied  heart-muscle  can  not  be  abrogated  in  a 
moment.  It  is  equally  obvious  that  the  other  factor  in  heart- 
power  can  be  modified  at  once  to  suit  the  new  and  lesser 
requirements.  And  this,  probably,  is  the  method  nature  adopts  to 
avoid  excessive  heart-action  and  an  excess  of  blood  in  important 
organs  after  labor.  The  heart -beats  are  reduced  some  twenty  to 
thirty  in  a  minute. 

Changes  in  the  Urinary  System  After  Labor. — The  phy- 
sician is  often  annoyed  in  obstetrical  practice  to  find  that  many 
women  after  labor  are  unable  to  urinate  and  consequently  require 
the  use  of  a  catheter,  which  must  be  employed  in  many  cases  by 
the  physician  himself,  especially  in  country  practice. 

To  comprehend  the  changes  in  the  urinary  system  it  is 
necessary  again  to  revert,  for  a  moment,  to  pregnancy.  The 
main  changes  in  the  kidney,  bladder,  and  urine,  in  that  con- 
dition may  be  thus  summarized:  The  kidneys,  by  reason  of 
additional  supply  of  blood  and  extra  work  to  do,  are  hyper- 
trophied ;  the  urine  is  increased  in  water,  diminished  in  solid 
constituents,  except  chlorids.  The  bladder,  in  pregnancy, 
from  the  pressure  of  the  gravid  uterus  behind,  is  unable  to 
expand  in  a  normal  manner,  but  must  accustom  itself  to  a 
distention,  chiefly  upward.  When  the  uterus  is  empty  and 
has  shrunk  to  half  its  former  size,  the  bladder  has  room  at 
once  to  distend  in  all  directions,  and  can  thus  hold  a,  very 
large  quantity  of  urine  before  its  walls  are  subjected  to  the 
same  degree  of  tension  to  which  they  were  accustomed  dur- 
ing pregnancy.  Thus  large,  quantities  of  urine  may  collect 
before  there  is  a  disposition  to  urinate.  Moreover,  the  abdomi- 
nal walls,  so  long  kept  on  the  stretch,  are  suddenly  released 
from  the  intra-abdominal  pressure,  and  do  not  for  some  time 
regain  their  tone  ;  so  that  the  action  of  the  abdominal  muscles, 
which  are,  perhaps,  the  chief  factors  in  emptying  the  blad- 
der, is,  to  some  extent,  inhibited.  In  some  women  recently 
delivered  the  abdomen  is  scaphoid,  so  that  a  contraction  of 
the  abdominal  muscles  actually  decreases,  instead  of  increasing, 
intra-abdominal  pressure.  There  is  a  third  reason  for  the 
retention  of  urine  after  labor  :  The  tissues  immediately  behind 
the  symphysis  pubis  bear  the  brunt  of  the  pressure  of  the  child's 
head  as  it  descends  the  birth-canal ;  and  this  pressure  is  exerted 
not  directly  forward,  but  to  one  side  or  the  other,  by  the  oblique 
position  of  the  head ;  the  tissues  about  the  urethra  are  left  edema- 


THE  PUERPERAL  STATE.  359 

tous  after  labor,  from  the  contusion  they  have  suffered,  and  the 
urethra  is  dragged  a  httle  to  one  side,  so  that  in  a  twofold  man- 
ner the  urethral  canal  is  partially  occluded,  namely,  by  the  edema 
of  surrounding  parts  and  by  the  acquired  tortuosity  in  its  course. 
The  urine  itself  does  not  differ  much  from  that  of  pregnancy. 
The  water  is  increased;  the  urea  and  solids  are  both  relatively 
and  actually  below  the  normal.  Glycosuria  is  quite  common. 
Blot  claims  that  the  sugar  in  the  urine  is  the  result  of  the  absorp- 
tion of  lactose  from  the  mammary  glands,  and  that  the  larger  the 
secretion  of  milk,  the  greater  the  quantity  of  sugar  in  the  urine, 
and  therefore  he  proposed  that  the  quantity  of  sugar  in  the  urine 
be  taken  as  a  test  for  the  suitability  of  a  wet-nurse.  It  has  been 
claimed,  by  others,  that  the  sugar  has  a  hepatic  origin. 

About  50  per  cent,  of  puerperae  have  albuminuria. 

Fischel  declares  that  peptonuria  is  a  constant  phenomenon 
of  the  normal  puerperium.^ 

The  sweat=glands  after  labor  are  unusually  active.  The 
skin  of  a  pregnant  woman  is  often  harsh  and  dry,  and  during 
labor,  unless  the  muscular  effort  is  great  or  the  weather  warm, 
the  same  condition  of  the  skin  persists.  But  in  the  puerperal 
state  the  sweat  secretion  is  profuse  ;  the  skin  is  constantly  moist, 
and  during  sleep  the  secretion  may  become  excessive.  This 
action  of  the  sweat-glands  plays  an  important  part  in  the  involu- 
tion of  the  whole  organism  after  labor.  It  is  one  of  the  factors 
by  which  the  hydremia  of  pregnancy  is  corrected,  and  by  the 
dissipation  of  heat  that  accompanies  the  rapid  evaporation  of 
water  all  over  the  body  the  temperature  in  the  puerperal  state  is 
retained  at  a  normal  level,  in  spite  of  many  provocations  to  fever. 

The  lungs  after  labor  take  on  a  slightly  different  action. 
Their  capacity  is  increased,  for  the  pressure  from  below  is  re- 
moved and  the  play  of  the  diaphragm  is  freer.  Each  inspiration 
drawing  in  more  air  than  before,  the  number  of  respirations  in 
the  minute  is  lessened;  the  breathing  is  deeper,  fuller,  quieter,  and 
slower  than  it  was  during  pregnancy,  and  the  expired  air  contains 
an  excess  of  water  and  of  effete  products,  the  result  of  tissue  de- 
struction. As  a  result  of  the  great  excretion  of  water  from  the  kid- 
neys, the  skin,  and,  to  a  lesser  extent,  the  lungs,  the  thirst  of  the 
lying-in  woman  is  increased  ;  the  appetite,  on  the  other  hand,  is 
much  diminished.  One  can  understand  the  last  statement  if  he  re- 
calls the  fact  that  more  than  a  pound  of  meat  in  the  involuting 
uterus  is  absorbed  into  the  system  during  the  puerperium,  and  if  he 
remembers  that  the  woman  is  Ix'ing  in  bed  absolutely  quiet  and 
expending  no  force  whatever  in  muscular  action.  There  is  still 
another  factor  to  account  for  the  disinclination  toward  food.  Dur- 
ing pregnancy  there  is  no  one  tissue,  except  that  contained  within 

'  "Arch.  f.  Gyn.,"  Bd.  xxiv  u.  xxvi,  S.  120  u.  400. 


360  LABOR  AND   THE  PUERPERIUM. 

the  developing  uterus,  which  increases  with  so  much  rapidity  as 
the  subcutaneous  fat.  It  seems  as  if  there  were  provided  by  na- 
ture a  store  of  material  which  shall  take  the  place  of  food  in  sup- 
plying heat  and  force  during  a  period  when  woman  in  her  natural, 
primitive  state  could  not  be  supposed  to  provide  for  herself. 
This  deposition  of  subcutaneous  fat  during  pregnancy  and  its 
subsequent  absorption  during  the  lying-in  period  account  for 
the  remarkable  dianges  in  weight  which  may  be  noted  in  a 
woman  during  pregnancy  and  after  labor.  This  is  a  matter 
of  some  practical  importance,  which  does  not  usually  obtain  the 
attention  that  it  deser\'es.  It  has  been  studied  systematically  by 
Gassner  and  later  by  Baumann.  According  to  Gassner,  the  gain 
in  weight  during  pregnancy  and  the  loss  afterward  are  about  one- 
thirteenth  of  the  body-weight.  This,  I  am  inclined  to  think,  from 
some  investigations  of  my  own,  is  an  underestimate,  and  Bau- 
mann's  observations  bear  me  out;  he  found  that  the  loss  of  body- 
weight  was  about  one-tenth  after  labor,  the  greater  part  of  it,  of 
course,  occurring  in  the  first  week,  when  a  woman  of  average 
weight  loses  some  nine  or  ten  pounds. 

All  the  remarkable  changes  observed  in  the  lying-in  woman 
occasion  no  manifestation  of  disease,  not  even  fever.  This 
assertion  some  years  ago  would  have  been  incorrect,  for  fever  was 
so  common  in  the  puerperal  state  that  it  was  regarded  as  physio- 
logical ;  it  occurred  usually  within  the  first  few  days  after  labor 
and  as,  at  this  time,  there  were  marked  manifestations  of  con- 
gestion in  the  breasts,  due  to  the  inception  of  lactation,  it  was 
called  milk  fever.  In  reality  it  was  the  fever  of  infection.  If, 
however,  the  temperature  in  the  puerperal  state  is  studied  closely, 
it  must  be  confessed  that  there  is  some  little  irregularity,  but  that 
irregularity  is  measured,  in  the  normal  case,  by  tenths  of  degrees. 
Directly  after  labor,  for  instance,  the  body-heat  is  always  a  little 
raised. 

Although  there  is  distinctly  no  such  thing  as  milk  fever, 
the  temperature  is  slightly  affected  when  the  breasts  suddenly 
assume  activity;  but  the  rise  is  rarely  more  than  a  few  tenths  of  a 
degree. 

So  many  causes,  transitory  in  their  effect,  can  produce  slight 
disturbances  in  the  temperature  of  the  lying-in  woman,  who  is 
peculiarly  sensitive  to  external  influences,  that  the  rigid  boundary 
which  divides  fever  from  a  normal  temperature  at  other  times 
must  be  a  trifle  relaxed.  Thus,  it  is  agreed  among  obstetricians 
not  to  regard  as  fever  a  transient  rise  of  temperature,  lasting  only 
a  few  hours,  which  does  not  go  above  100.5°.  This  is  the  so-called 
physiological  limit  to  the  rise  of  temperature  in  the  puerperal  state. 

The  Mammary  Changes  in  the  Puerpera. — Heretofore  the 
involution  of   important  organs   and    systems   in   the  puerperal 


THE   PUERPERAL    STATE. 


361 


state  has  claimed  attention.  The  mammary  action  after  dehvery 
is  a  process  of  evolution.  The  mammary  glands,  as  their  name 
denotes,  are  glandular  organs,  only  reaching  their  full  develop- 
ment, as  a  rule,  in  the  female  ;  situated,  usually,  toward  the  lateral 
aspect  of  the  pectoral  region  ;  occupying  the  space  bounded 
above  by  the  third  and  below  by  the  sixth  rib,  to  the  inner  side 
by  the  edge  of  the  sternum,  to  the  outer  side  by  the  axillary 
line.  They  are  derived  from  the  epiblastic  layer  of  the  blasto- 
dermic membrane,  and  belong  essentially  to  the  skin,  as  do  the 


cv 


Fig.  230. — CE,  Cuboidal  epithelial  cells  ;  F,  fat  globules  stained  black  with 
osmic  acid,  and  seen  both  in  the  cells  and  in  the  central  cavity  of  the  acini ;  CV, 
connective-tissue  frame  with  blood-vessels.     Magnified  600  diameters  (C.  Heitzmann). 

A  B 


Fig.  231. — Mammary  gland  of  dog,  showing  the  formation  of  the  secretion: 
^,  Medium  condition  of  growth  of  the  epithelial  cells;  B,  a.  later  condition  (after 
Heidenhain ). 

sweat  and  sebaceous  glands.  They  are  closely  akin  to  the 
latter,  occurring  in  rare  instances  on  indifferent  parts  of  the 
body,  as  the  axilla,  the  abdomen,  or  even  the  thighs,  where  a 
sebaceous  gland  has  undergone  a  specialized  development.  In 
the  female  they  are  hemispherical  in  shape  ;  they  are  held  in 
their  normal  position  upon  the  pectoral  muscles  by  the  super- 
ficial fascia,  which  splits  into  two  layers,  one  running  above, 
the  other  below,  the  breast.    Externally,  a  little  below  the  middle 


362 


LABOR  AND  THE  PUERPERIVM. 


of  the  organ,  is  a  protuberance, — the  nipple  ;  around  this  is  an 
area  of  pigmented  skin, — the  areola  ;  in  this  space  are  a  number  of 
large  sebaceous  glands, — the  glands  of  Montgomery.  Internally 
the  breast  is  divided  into  excretory  ducts,  lobes,  and  lobules  ; 
between  the  lobes  and  lobules  are  connective  tissue  and  fat. 
The  lobules  are  ultimately  divided  into  little  vesicles ;  these 
empty  into  a  small  excretory  duct ;  the  small  excretory  ducts 
from  contiguous  lobules  unite  to  form  a  single  large,  lactiferous 
canal ;  of  these  there  are  some  fifteen  or  twenty,  each  conveying 
the  secretion  from  a  separate  lobe  to  the  nipple  ;  just  before 
emerging  upon  the  surface  of  the  nipple  each  duct  is  dilated  to 


Fig,  232. — Mammary  gland  :  I, 
Lacteal  ducts;  2,  glandular  acinus 
(Playfair). 


Fig.  233. — Colostrum  and  ordinary 
milk-globules,  first  day  after  labor; 
primipara  aged  nineteen  (after  Hassall). 


form  a  small  ampulla  or  reservoir  for  the  milk  ;  as  it  passes 
through  the  skin  of  the  nipple  it  is  again  contracted.  The  epi- 
thelium of  the  gland  is  continuous  with  that  of  the  integument ; 
in  the  superficial  portions  of  the  lactiferous  ducts  it  is  squamous  ; 
in  the  deeper  portions  of  the  gland,  columnar.  The  function  of 
the  gland  is  the  secretion  of  milk. 

Colostrum. — During    the    latter 
opalescent   fluid   may  be  squeezed 
after  labor  this  fluid  is  somewhat  increased  in  quantity,  and  be 
comes  a  little  whiter  and  more  opaque. 


part   of    pregnancy   a   thin, 
out  of  the   breast ;    directly 


THE   PUERPERAL   STATE. 


363 


At  the  end  of  about  forty-eight  hours  a  decided  change 
takes  place  in  the  breasts  ;  they  suddenly  enlarge  ;  the  skin  over 
them  becomes  tense  ;  the  cutaneous  veins  are  engorged  with 
blood,  and  show  swollen  and  distinct  beneath  the  skin  ;  the 
nipple  projects  ;  to  the  feel  the  breasts  are  hard  and  lumpy  ;  to 
the  woman  they  are  painful  and  tender  on  pressure.  If  the 
child  is  applied  to  the  nipple,  there  runs  out,  almost  without 
suction,  a  quantity  of  human  milk — a  fluid  different  from  the 
colostrum  just   described.     It   is   white,    opaque,    of   a   specific 


15  < 


3  4 

Fig.  234. — The  production  of  milk.  Section  of  the  mammary  gland  of  a  nursing 
puerpera  (Bumm):  I,  Epithelium  of  acinus  inactive;  2,  epithelium  compressed  by 
milk  in  acinus;  3,  4,  5,  epithelium  actively  secreting  milk;  6,  intra-acinous  connec- 
tive tissue ;  7,  capillaries ;  8,  secreting  epithelial  cells  with  large  fat  drops  in  the 
protoplasm,  the  nucleus  pressed  into  cell  wall ;   9,  milk. 


gravity  about  1025,  is  said  to  have  a  sweet,  agreeable  taste,  and 
is  without  odor. 

The  influences  which  determine  milk  secretion  after  childbirth 
are  still  a  mystery.  Lactation  is  observed  even  though  the  spinal 
and  sympathetic  nerve  connection  with  the  genitalia  is  severed. 
Indeed,  lactation  has  occurred  in  the  mammary  gland  of  a  rabbit 
transplanted  to  its  ear  five  months  before.  It  may  be  an  ovarian 
secretion,  perhaps  that  from  the  corpus  luteum,  which  stimulates 
milk  production,  but  this  theory  does  not  account  for  milk  secre- 


364  LABOR  AND  THE  PUERPERIUM. 

tion  in  the  infant  during  the  first  few  days  after  birth,  in  young 
girls,  in  cases  of  imaginary  pregnancy,  in  women  with  pelvic  or 
abdominal  tumors,  and  in  men. 

The  quantity  of  milk  secreted  in  the  twenty-four  hours  is  dif- 
ficult to  determine.  It  might  seem  easy  enough  to  draw  the 
milk  from  the  breast  at  stated  intervals  with  a  breast-pump 
and  to  measure  it,  but  it  is  difficult  to  get  a  breast-pump  as 
mechanically  effective  as  a  child's  mouth,  and,  moreover,  the 
secretion  of  milk  depends,  to  some  extent,  upon  the  maternal 
emotion  ;  the  breast  might  almost  be  described  as  an  erectile, 
organ ;  certainly,  the  sight  of  the  child  arouses  a  maternal 
instinct  which  sends  an  additional  blood-supply  to  the  mammary 
gland  and  undoubtedly  increases  the  supply  of  milk.  It  has 
been  estimated  that  at  first  the  quantity  of  milk  is  about  300  to 
400  grams  (10  to  13^  fl.  oz.)  ;  by  the  seventh  day  it  is  400  to 
500  grams  (14  to  17  fl.  oz.)  ;  after  the  second  week,  1500  to  2000 
grams — i  ^^  to  2  liters  (3  to  4  pints). 

In  a  microscopic  section  of  a  mammary  gland,  procured 
during  lactation,  there  may  be  seen  large  epithelial  cells  in  the 
process  of  proliferation.  Toward  their  inner  periphery  may  be 
seen  globules  of  fat.  One  of  two  things  must  happen  to  account 
for  the  production  of  the  milk  :  either  the  whole  cell,  which 
has  begun  to  show  signs  of  fatty  degeneration,  or  rather  fatty 
metamorphosis,  is  cast  off,  then  bursts  and  discharges  its  con- 
tained fat,  as  well  as  other  cell-contents,  into  the  liquid  medium 
which  has  exuded  from  the  blood,  or  else  each  cell,  having  accu- 
mulated its  store  of  fat,  discharges  it  in  little  globules,  along 
with  the  casein,  which  must  also  be  derived  from  the  cell- 
contents.     The  latter  process  is  the  one  generally  accepted. 

The  Diagnosis  of  the  Puerperium. — Occasionally  it  is  impor- 
tant for  a  physician  to  be  able  to  decide  by  an  appeal  to  his  own 
senses,  without  regard  to  the  woman's  statement,  whether  or  not 
she  has  been  recently  delivered.  Women  accused  of  infanticide, 
for  example,  may  deny  their  recent  delivery.  The  diagnosis, 
in  such  a  case,  is  not  difficult.  The  large  uterus,  reaching  to 
the  umbilicus  ;  the  bloody  discharge,  showing,  under  the  micro- 
scope, decidual  cells  ;  the  secretion  in  the  breasts  ;  the  charac- 
teristic fragments  of  decidua  that  may  be  scraped  out  of  the 
uterine  cavity  with  a  curet ;  the  rents  in  the  cervix,  the  vaginal 
mucous  membrane,  and  the  perineum  ;  the  relaxed  abdominal 
walls,  and  the  striae  upon  them, — all  unite  to  make  the  diagnosis 
easy  to  establish  and  absolutely  sure. 

Management  of  the  Puerperium. — The  prevention  of  in- 
fection must  be  the  chief  care  of  both  doctor  and  nurse  in  charge 
of  a  puerpera  (see  The  Preventive  Treatment  of  Puerperal  Sepsis), 


THE  PUERPERAL  STATE.  365 

Having  secured,  so  far  as  possible,  a  perfect  cleanliness  of  physi- 
cian, patient,  all  her  surroundings  and  attendants,  and  of  the  air 
of  the  room  in  which  the  woman  lies,  one  has  performed  by  far 
the  most  important  part  of  his  duty  in  the  management  of  the 
puerperal  state,  and  has  averted  the  commonest  and  most  fatal 
accident  of  this  period — septic  infection.  Being  secure  of  this 
most  desirable  result,  the  physician  may  turn  his  attention  to 
some  lesser  matters,  of  no  little  importance,  however,  to  the 
comfort  and  even  safety  of  the  patient. 

Visits. — It  is  wise  to  wait  in  the  house  for  an  hour  after  the 
woman's  delivery,  to  see  that  there  is  no  hemorrhage.  She 
should  be  visited  again  in  about  twelve  hours  ;  then  once  a  day 
for  the  first  two  weeks,  every  other  day  during  the  third  week, 
and  once  or  twice  in  the  fourth  week.  For  the  first  week  at 
least  the  following  items  should  be  investigated  routinely  at  each 
visit :  The  pulse  ;  the  temperature  ;  the  odor,  quantity,  and  char- 
acter of  the  lochia  ;  the  condition  of  the  bladder  and  size  of  the 
womb,  learned  by  abdominal  palpation  ;  the  condition  of  the 
breasts  and  nipples  ;  the  occurrence  of  after-pains  ;  the  evacua- 
tion of  the  bladder  and  bowels,  and  last,  but  by  no  means  least, 
the  condition  of  the  infant.  Many  physicians  fall  into  the  habit 
of  neglecting  the  baby  altogether.  There  could  be  no  worse 
policy,  not  to  speak  of  higher  considerations.  The  mother 
resents  an  indifference  to  her  infant's  condition,  and  a  failure  to 
make  a  routine  investigation  at  each  visit  of  the  child's  feeding, 
sleeping,  and  gain  in  development ;  of  its  umbilicus,  its  bowel 
and  bladder  evacuations,  and  digestion,  often  results  in  a  failure 
to  correct  some  abnormality  until  it  is  too  late.  Many  a  sudden 
and  inexplicable  death  in  the  new-born  could  have  been  avoided 
by  greater  watchfulness  and  care. 

Rest  and  Quiet. — The  woman  recently  delivered  is  the  picture 
of  perfect  restfulness  and  repose.  There  is  reason  enough  for 
this  mental  and  physical  quiet  after  delivery.  The  relief  from  great 
suffering  and  tremendous  muscular  effort  would  naturally  induce 
a  feeling  of  lassitude,  and  fortunately  it  is  preeminently  the 
case  after  labor,  for  this  condition  of  perfect  repose  is  most 
favorable  for  the  occurrence  of  the  complicated  phenomena  of 
the  puerperium  without  detriment  to  the  woman's  health.  It 
seems  almost  superfluous  to  insist  upon  the  adx'isabiht}'  of  ac- 
cepting this  hint  from  nature  in  the  management  of  the  puerperal 
state, — of  preventing  any  mental  or  physical  disturbance,  mus- 
cular effort,  a  glaring  light,  loud  conversation,  and,  more  than  all, 
the  entrance  into  the  lying-in  room  of  a  single  person  whose 
presence  is  not  necessary, — and  yet  this  is  a  matter  that  in  many 
cases  requires  the  physician's  express  attention.      Among  more 


3^6  LABOR  AND   THE  PUERPERIUM. 

ignorant  people  particularly,  and  especially  if  there  has  been  some 
unusual  complication  or  accident  in  the  labor,  the  patient,  upon 
the  second  visit,  may  be  found  restless,  with  a  rapid  pulse,  an 
anxious  expression,  and  an  elevated  temperature,  and  on  in- 
quiry it  is  learned  that  a  constant  stream  of  her  female  neigh- 
bors has  been  pouring  into  her  room  with  minute  inquiries  into 
the  particulars  of  the  case,  and  often  with  gloomy  forebodings 
as  to  the  result,  based  upon  their  recollection  of  just  such  a  case 
which  ended  fatally.  It  was  the  custom  in  France  in  the  seven- 
teenth century  to  baptize  the  infant  on  the  third  or  fourth  day,  when 
a  collation  was  served  in  the  lying-in  room,  to  which  all  the  friends 
of  the  family  were  invited,  who  were  expected  to  drink  the  mother's 
health  with  much  hilarity  and  many  congratulations, — a  ceremony 
lasting  through  a  whole  afternoon.  Mauriceau  speaks  of  this  as 
a  "very  ill  custom."  We  must  agree  with  him,  and  should  be 
inclined  to  go  to  the  opposite  extreme  in  enforcing  rest  and  seclu- 
sion during  the  whole  lying-in  period. 

The  physician  must  give  specific  directions  in  regard  to  the 
following  matters,  under  the  head  of  Rest  and  Quiet : 

1.  The  position  that  the  patient  must  occupy  in  bed,  and 
how  long  she  must  retain  it.  The  length  of  time  she  must 
remain  in  bed.  The  earliest  date  she  may  stand  upon  her  feet, 
and  the  time  when  she  may  go  down-stairs. 

2.  The  degree  of  quiet  and  decorum  to  be  observed  in  the 
room  ;  and — 

3.  The  admission  of  visitors. 

The  rules  in  regard  to  these  matters,  expressed,  as  rules, 
dogmatically,  might  run  as  follows  : 

I.  The  patient  shall  lie  flat  on  her  back  and  shall  not  be 
allowed  another  posture  for  at  least  a  week.-^  For  the  first  six 
hours  after  labor  the  head  shall  not  be  supported  by  a  pillow, 
but  shall  be  on  a  level  with  the  body,  in  order  to  avoid  a 
disposition  to  cerebral  anemia  and  syncope,  from  the  greatly 
decreased  abdominal  pressure. 

The  woman  must  lie  in  bed  until  the  involution  of  the  uterus 
is  so  far  complete  that  the  fundus  uteri  has  sunk  to  the  level  of 
the  symphysis  pubis  or  below  it.  It  is  a  safe  rule  to  insist  upon 
strict  confinement  to  bed  for  fourteen  days.  Then  the  patient 
may  be  allowed  to  shift  herself  from  the  bed  onto  a  lounge 
rolled  alongside  of  it,  passing  the  day  upon  the  lounge  and  sit- 
ting up  as   long  at  a  time  as  she   can  without  fatigue.      At  the 

1  This  rule  is  sure  to  be  a  little  relaxed  by  the  patient  and  nurse.  If  the  former 
is  allowed  to  roll  about  the  bed  at  will,  the  ligaments  of  the  uterus  are  stretched  as 
the  uterus  falls  from  side  to  side  with  the  movements  of  the  patient,  and  displace- 
ments ultimately  are  more  likely  than  if  she  had  kept  quiet.  There  is,  besides,  the 
rather  remote  danger  of  displaced  thrombi  and  sudden  death  from  embolism. 


THE  PUERPERAL  STATE.  367 

end  of  three  weeks  she  begins  to  walk  about  the  room,  and  at 
the  end  of  four  goes  down-stairs  for  the  first  time. 

2.  The  woman's  rest  must  be  mental  as  well  as  physical ; 
therefore,  no  loud  noises  should  offend  her  ear,  no  glaring  light 
should  irritate  the  eye,  and  no  extended  conversation  should  be 
allowed  in  the  lying-in  room ;  at  any  rate,  for  the  first  few 
days. 

3.  No  visitor  should  be  allowed  in  the  lying-in  room  except 
the  patient's  mother  and  her  husband,  and  it  is  sometimes  neces- 
sary to  restrict  the  visits  as  to  frequency  and  length. 

These  rules  in  regard  to  quiet  after  labor  will  suit  the  aver- 
age case  among  the  upper  classes.  They  must,  however,  be 
modified  on  occasion.  The  length  of  time,  for  instance,  required 
for  the  involution  of  the  uterus  varies  greatly  in  different  classes 
of  society.  An  Indian  tribe  on  the  march  does  not  halt  because 
a  woman  falls  in  labor ;  she  retires  to  the  bushes,  gives  birth  to 
her  infant,  cuts  the  cord,  dresses  the  child,  and  plunges  into 
the  nearest  stream  to  cleanse  herself;  remounting  her  pony,  she 
soon  rejoins  her  tribe  with  the  new-born  infant  slung  on  her 
back.  The  involution  of  her  uterus  goes  on  rapidly,  in  spite  of 
this  heroic  treatment.  In  the  Frauenklinik  in  Munich,  in  which 
the  author  once  served  as  volunteer  interne,  and  where  the  pa- 
tients are  mainly  strong  Bavarian  peasant  girls,  the  fundus  of  the 
uterus  was  usually  beneath  the  symphysis  pubis  on  the  sixth  day. 
On  that  day  the  patient  left  her  bed  ;  the  following  morning  she 
walked  out  of  the  hospital  with  her  infant  in  her  arms.  In  the 
more  artificial  life  of  the  upper  classes  much  of  the  primitive 
woman's  physical  vigor  is  surrendered  for  increased  mental  cul- 
ture. In  these  women  labor  is  usually  difficult  and  painful,  if 
not  dangerous  ;  the  puerperaf  state  is  often  more  complicated 
than  it  should  be,  and  involution  of  the  uterus  may  be  delayed. 

No  patient  should  be  allowed  to  leave  her  room  before  a 
careful  vaginal  examination  has  been  made,  to  ascertain  the 
position  of  the  uterus. ^  This  one  examination,  however,  is  not 
sufficient.  Even  after  involution  is  almost  completed,  when  the 
woman  resumes,  to  a  certain  extent,  her  normal  activity,  a  uterine 
displacement  is  not  unlikely  to  occur.  Overexertion  or  exposure 
will  almost  certainly  bring  on  a  renewal  of  the  bloody  lochia ; 
the  involution  of  the  uterus  may  be  arrested  before  its  perfect 
completion  ;  even  septic  inflammation  may  attack  the  uterus  and 
its  appendages  as  late  as  the  fourth  week.     It  should  be  an  invari- 

'  If  the  uterus  is  found  retroverted  between  the  third  and  fourth  week,  it  should 
be  replaced,  and  the  patient  instructed  to  assume  the  knee-chest  posture  twice  a  day 
for  five  minutes  at  a  time.  I  find  the  postural  treatment  of  displacements  of  the 
puerperal  uterus  permanently  successful  in  a  considerable  proportion  of  cases.  A  pes- 
sary is  contraindicated  before  the  sixth  week. 


368  LABOR  AND   THE  PUERPERIUM. 

able  rule  of  practice,  therefore,  to  examine  every  child-bearing 
woman  six  weeks  after  her  delivery,  digitally  and  with  the  specu- 
lum, noting  the  position  of  the  uterus,  its  involution,  the  condition 
of  the  pelvic  connective  tissue  and  uterine  appendages,  possible 
injuries  to  the  cervix,  anterior  vagmal  wall,  and  pelvic  floor, 
erosions  of  the  cervix,  the  condition  of  the  abdominal  wall,  and  the 
character  of  the  uterine  discharge.  Abnormahties  are  often  found 
at  this  period,  which  were  not  noticeable  or  were  not  present  before 
the  woman  left  her  room.  The  question  whether  the  routine 
administration  of  ergot  would  insure  perfect  involution  or  hasten 
its  completion  has  occurred  to  many  minds,  and  has  found  its 
answer  in  practical  experimentation.  Numbers  of  women  have 
been  placed  on  a  routine  treatment  of  ergot  three  times  a  day, 
and  the  progress  of  these  cases  has  been  carefully  compared  with 
that  of  an  equal  number  of  women  left  to  nature.  The  result 
of  these  observations  has  not  been  favorable  to  ergot  as  a  sure 
means  of  shortening  the  duration  of  the  puerperal  state:  nothing 
was  gained  in  point  of  time,  while  disadvantages  were  found  in  this 
plan  of  treatment  that  might  have  been  foreseen.  The  stomach 
rebels  against  a  prolonged  use  of  the  drug  in  considerable  quanti-. 
ties.  While  contracting  the  uterus,  it  has  an  astringent  action 
also  on  the  breast  and  so  diminishes  milk  secretion,  and,  passing 
from  the  maternal  blood  into  the  milk  and  into  the  infant's  stomach, 
it  exerts  an  unfavorable  influence  upon  both  mother  and  child. 

The  diet  is  a  matter  of  no  small  importance,  about  which 
there  is  considerable  difference  of  opinion.  On  the  one 
hand,  it  is  held  that  the  woman  after  labor  is  weak  from  loss  of 
blood  and  from  fatigue;  that  she  must,  therefore,  receive  the 
most  nourishing  food  in  the  largest  possible  quantities.  More- 
over, that  the  demand  which  will  soon  be  made  upon  her 
economy  for  the  nourishment  of  the  child  is  an  additional  reason 
for  the  administration  of  a  generous  diet  from  the  first.  But  a 
close  observation  of  nature  should  lead  to  the  opposite  view. 
A  large  part  of  the  involuting  uterus  is  absorbed  into  the 
system;  some  two  pounds  of  meat  are  thus,  as  it  were,  de- 
voured, the  greater  part  of  it  in  the  first  few  da3^s  of  the 
puerperium.  A  large  quantity  of  fat  is  stored  up  in  the  body 
during  pregnancy  with  the  express  purpose,  it  would  seem,  of 
providing  a  means  of  supporting  the  woman  during  the  early 
part  of  the  puerperal  state.  Thus  nature  provides  a  sustenance 
which  in  quantity  certainly  appears  sufficient  for  at  least  the 
first  few  days  after  confinement,  and  in  form  and  manner  of 
ingestion,  so  to  speak,  is  best  calculated  to  support  the  woman's 
strength,  with  none  of  the  expenditure  of  force  involved  in 
mastication  and   digestion.      Moreover,  it  must  be  remembered 


THE  PUERPERAL  STATE.  369 

that  almost  all  the  vital  functions  are  performed  in  a  sluggish 
manner  for  the  first  few  days  after  labor.  The  pulse  is  less 
rapid,  the  respiration  slower,  the  bowels  are  inactive,  and  there 
should  be  no  voluntary  muscular  effort.  All  this  seems  to 
argue  for  the  wisdom  of  a  system  which  allows,  for  the  first 
few  days,  nourishment  small  in  quantity,  of  a  form  easily  ingested, 
and  of  a  quality  readily  digested.  After  the  third  day,  however, 
a  new  element  must  be  taken  into  account.  At  that  time  there 
begins  the  milk  secretion,  which  undoubtedly  entails  a  great 
drain  on  the  whole  system  to  provide  the  large  quantity  of  fat 
and  nitrogenous  material  which  are  excreted  when  the  breasts  have 
assumed  their  full  activity.  To  meet  this  additional  demand 
upon  the  resources  of  the  body  the  simple  diet  of  the  first  few 
days  should  be  materially,  though  gradually,  increased  ;  for  the 
first  onset  of  the  physiological  mammary  action  is  usually  so 
violent  as  to  stop  just  short  of  a  pathological  condition, — inflam- 
mation,— and  suddenly  to  exhibit  large  quantities  of  nutritious 
food  at  this  time  would  very  likely  cause  a  transgression  across 
the  boundary -line  between  health  and  disease.  This,  however, 
is  micre  theoretical  reasoning,  and  if  applied  in  practice  it  fails  to 
give  the  best  results,  the  system  dependent  upon  it  should  be 
ruthlessly  discarded,  no  matter  how  reasonable  it  may  appear. 
But  a  practical  test  has  given  the  result  that  might  be  expected. 
No  one  who  has  compared  the  two  methods — one,  of  giving  a 
forced  diet  from  the  first ;  the  other,  of  giving  a  very  light  diet, 
chiefly  of  milk,  for  the  first  two  days,  and  afterward  gradually 
increasing  it  until,  on  the  sixth  or  seventh  day,  the  patient  is 
taking  the  food  that  would  be  suitable  to  any  healthy  person 
confined  in  bed  without  physical  exercise — can  fail  to  notice  that 
the  latter  plan  secures  a  far  greater  immunity  from  congestion  of 
the  genitalia  and  breasts,  from  irregularity  in  the  milk  secretion, 
and  from  disturbances  of  the  stomach  and  bowels. 

Urination. — The  tendency  to  retention  of  urine  that  is  so 
often  met  with,  especially  among  women  city  bred  and  in  easy 
circumstances,  has  already  been  noticed.  This  is  an  abnor- 
mality in  the  puerperal  state  of  civilized  woman  that  is,  per- 
haps, as  annoying  as  any  one  feature  of  a  normal  case.  Its 
causes  have  already  been  described.  Its  detection  would  seem 
perfectly  easy,  and  yet  it  is  just  as  easy  to  overlook  it  without 
the  careful  attention  which  should  be,  but  is  not  always,  directed 
toward  this  point.  It  is  a  common  experience  for  a  consultant 
to  be  asked  to  see  a  woman  some  days  after  labor,  because  the 
attending  physician  thinks  that  alongside  the  uterus  there  is  a 
large  and  peculiar  abdominal  tumor,  and  the  patient  suffers  great 
pain.  What  is  taken  for  the  uterus  is  an  immensely  distended 
24 


370  LABOR  AND  THE  PUERPERIUM. 

bladder,  reaching  half-way  or  quite  to  the  umbilicus;  the  peculiar 
abdominal  tumor  is  the  uterus  itself  pushed  far  upward  and  to  one 
side,  almost  always  the  right.  Catheterization  removes  immedi- 
ately both  tumor  and  pain.  The  mistake  on  this  point  often 
arises  from  the  trust  that  the  physician  puts  in  the  woman's 
statement  that  she  has  urinated  regularly.  One  should  never 
trust  any  one's  assertion  as  to  action  of  the  bladder,  but  should 
always  examine  for  himself,  by  abdominal  palpation,  to  see 
if  it  is  full  or  not.  A  nurse  sometimes  falsely  asserts  that 
her  patient  has  urinated,  because  she  is  ashamed  to  confess 
her  inabihty  to  pass  a  catheter.  If  the  urine  must  be  drawn, 
the  catheter  is  used  by  a  trained  nurse,  should  there  be  one. 
In  her  absence  the  physician  himself  must  attend  to  the 
catheterization ;  even  if  a  skilful  nurse  is  in  attendance,  the 
physician  is  not  infrequently  appealed  to,  as  the  nurse  can  not 
discover  the  urethra,  or  is  unable  to  insert  the  catheter.  It  is 
well,  therefore,  under  all  circumstances,  to  know  how  to  use  a 
catheter  and  to  have  a  definite  opinion  as  to  the  kind  of  instru- 
ment that  should  be  employed.  A  soft-rubber  catheter  is  to  be 
preferred,  because  it  is  incapable  of  doing  any  harm,  does  not 
irritate  the  urethra,  and  is  easily  cleansed  and  kept  clean. 
After  being  used  it  should  be  rinsed  out  and  should  be  kept  per- 
manently immersed  in  a  i  :  2000  solution  of  sublimate.  Before 
being  used  it  must  be  dipped  in  a  basin  of  sterile  water,  and  its 
tip  should  then  be  oiled.  The  hands  of  the  individual  who 
inserts  it  mus't  be  aseptic.  It  saves  time  and  is  safer  to  wear 
rubber  gloves,  which  have  been  soaked  in  a  i  :  looo  sublimate 
solution  or  have  been  boiled.  To  introduce  the  catheter,  it  is 
necessary  to  expose  the  urethra  to  view,  to  wipe  off  its  orifice, 
as  well  as  the  surrounding  mucous  membrane,  with  a  piece  of 
absorbent  cotton  moistened  with  a  sublimate  solution,  i  :  2000. 
The  catheter  is  then  inserted  directly  into  the  urethra,  so  that  it 
does  not  carry  with  it  into  the  bladder  some  of  the  decomposing 
vaginal  discharge,  which  would  be  likely  to  set  up  a  very  trouble- 
some or  a  very  dangerous  cystitis.  The  old  practice  of  locating 
the  urethra  by  the  sense  of  feel,  using  the  finger  of  the  left  hand  and 
then  introducing  the  catheter  held  in  the  fingers  of  the  right  hand, 
under  a  sheet,  is  unreservedly  condemned. 

In  the  Directions  to  Nurses,  appended  to  this  chapter, 
occurs  the  passage,  "Twelve  hours  after  labor  the  woman 
shall  be  catheterized,  and  after  that  three  times  a  day  if 
necessary."  Twelve  hours  may  seem  a  rather  long  period  to 
allow  urine  to  collect  after  labor  ;  but  the  bladder  is  capable  of 
great  distention  at  this  time  ;  almost  all  the  natural  processes 
are  sluggish  ;  the  kidneys  directly  after  labor  are  not  very  active, 


THE  PUERPERAL  STATE.  37 1 

and  if  the  catheter  is  used  too  soon,  the  patient  is  very 
likely  committed  to  its  use  throughout  the  greater  part  of  the 
lying-in  period,  whereas  if  the  woman  can  be  induced  to  urinate 
naturally  at  first,  there  will  be  no  difficulty  afterward.  At  the 
same  time  it  would  be  unwise  to  allow  an  overdistention  of  the 
bladder  ;  twelve  hours,  therefore,  is  a  good  compromise  time  for 
the  first  use  of  the  catheter.  After  that  three  times  a  day  is  usually 
quite  sufficient  ;  it  should  not  be  used  less  frequently,  and  if  the 
patient's  feelings  demand  it,  the  bladder  must  be  emptied  more 
frequently.  By  this  plan  it  is  necessary  to  use  the  catheter  in 
about  thirty  per  cent,  of  primiparce.  It  is  possible,  by  a  longer 
delay,  to  reduce  this  proportion  materially.  In  the  Baudelocque 
Clinic  they  wait  twenty-four  hours  or  longer  and  have  used  the 
catheter  in  6666  cases  only  twenty  times.  ^  Before  resorting  to 
catheterization  every  effort  should  be  made  to  induce  the 
woman  to  urinate  naturally.  Sometimes  this  is  accomplished  by 
putting  hot  water  in  the  bed-pan,  by  the  use  of  a  turpentine 
stupe  over  the  bladder,  and  by  the  sound  of  running  water. 

The  Bowels. — On  account  of  the  small  amount  of  food  in- 
gested during  the  early  part  of  the  puerperium,  the  flaccidity  of 
the  abdominal  walls,  the  torpor  of  the  intestinal  muscles  from 
long  pressure,  and  the  general  muscular  inactivity,  there  is  a  re- 
markable sluggishness  of  the  bowels,  and  an  exaggeration  of  the 
constipated  habit  almost  invariably  acquired  in  pregnancy.  This 
is  no  great  disadvantage  at  first,  as  the  food  is  principally  liquid 
and  small  in  quantity,  so  that  there  is  very  little  detritus  to  be 
thrown  off  by  the  intestines.  It  is  not  advisable,  however,  to 
allow  the  feces  to  accumulate  too  long.  If  the  woman  eats  in  a 
day  perhaps  a  third  of  what  an  ordinary  person  would  devour, 
by  the  third  day  there  would  be  a  considerable  collection  in  the 
lower  bowel  ;  at  this  time,  too,  the  diet  is  a  little  increased,  and 
the  sudden  onset  of  milk  secretion  on  the  third  day  always  seems, 
at  least,  to  threaten  an  inflammation  of  the  breasts,  which  might 
be  averted  by  a  derivative  and  depletive  course.  For  all  these 
reasons,  therefore,  it  is  customary  to  administer  as  a  routine 
treatment  a  laxative  on  the  evening  of  the  second  or  third  dav.  A 
good  routine  prescription  is  a  half-bottle  of  citrate  of  magnesia  on 
the  evening  of  the  second  day,  the  rest  of  the  bottle  the  follow- 
ing morning  before  breakfast,  and,  if  the  bowels  are  not  moved 
two  hours  later,  a  simple  enema.  If  the  patient  is  plethoric  or 
the  mammary  glands  are  swollen  and  tender,  a  more  active  saline 
purge  is  preferable. 

The  Mammary  Glands. — There  are  many  conditions  of  the 
breasts,  not  pathological   but  troublesome  to  deal  with,  of  such 

'Recht,  "These  de  Paris,"  1894. 


372 


LABOR  AND  THE  PUERPERIUM. 


frequent  occurrence  that  they  must  be  considered  in  the  manage- 
ment of  a  normal  case.  In  almost  every  instance  the  establish- 
ment of  lactation  is  accompanied  by  some  local  disturbance. 
The  increased  blood-supply  to  the  breast,  the  proliferation  of 
cells,  and  the  transudation  of  a  serous  exudate  are  phenomena 
usually  characteristic  of  inflammation.  The  enlarged  breast, 
the  engorged  veins  under  the  skin,  the  hard,  tense  feel  of  the 
gland-tissue,  and  the  great  tenderness,  all  seem  to  point  to  an 
inflammatory  attack  instead  of  a  natural  physiological  process. 
This  state  of  the  breasts  usually  demands  treatment  to  ameliorate 
the  discomfort  and  to  prevent  the  transition  of  a  natural  process 
closely  bordering  on  the  pathological  to  a  condition  of  actual 
disease.  If  the  engorgement  of  the  breasts  is  marked  and  the 
accompanying  symptoms  of  heat,  pain,  and  fullness  are  pro- 
nounced, the  administration  of  a  saline  purge  is  usually  sufficient 
to  relieve  some  part  of  the  mammary  congestion.  Care  must  be 
taken,  in  addition,  to  empty  the  breast.    For  this  purpose  nothing  is 


Fig.  235. — Diagram  pattern  for  Murphy-Cooke  breast  binder.  By  enlarging 
until  each  square  represents  a  square  inch,  and  tracing  an  outline,  a  binder  of  ordinary 
size  will  be  secured.  If  the  binder  is  cut  from  folded  muslin,  only  one-half  the  pat- 
tern need  be  made. 


SO  good  as  the  infant's  mouth,  which  should  be  applied  to  the  nip- 
ple regularly  every  two  hours.  If  the  child  dies,  does  not  empty 
the  breast,  or  is  weaned,  a  breast-pump  must  be  used,  and  the 
nurse,  in  addition,  should  rub  and  massage  the  breast  with  oiled  fin- 
ger-tips in  a  direction  toward  the  nipple,  thus  making  the  skin  more 
supple  and  emptying  the  breast  at  the  same  time.  The  constant 
dragging  upon  the  nipple  when  the  child  is  nursing,  the  pinchin.g 
and  squeezing  it  receives  from  the  infant's  gums,  and  its  continual 


THE  PUERPERAL  STATE. 


373 


moisture  from  milk  and  the  secretions  of  the  infant's  mouth,  all 
tend  to  bring  about  an  unhealthy  condition  of  the  skin  upon  and 
around  it.  It  becomes  at  tirst  irritated  and  inflamed,  then  ex- 
coriated, chapped,  and  fissured,  and,  consequently,  exceedingly 
sensitive  and  painful,  so  that  suckling  the  child  is  dreaded.  Nor 
is  this  the  only  disadvantage;  in  the  little  cracks  and  fissures 
the  milk  collects  and  decomposes  ;  the  patient  or  nurse  may, 
in  careless  handling  of  the  breasts,  deposit,  in  these  raw  places, 
pathogenic  micro-organisms,  and  the  consequence  is  very  likely 
to  be  septic  infection  of  the  connective  tissue  of  the  breast  and 
the  formation  of  a  mammary  abscess — of  all  the  minor  complica- 
tions of  the  puerperal  state  the  one  to  be  most  dreaded.  The 
preventive  treatment  of  this  complication  is  an  important  part  of 
the  management  of  the  puerperal  state.  The  main  thing,  ob- 
viously, is  to  keep  the  skin  healthy  and  clean.  This  is  done  by 
carefully  washing  the  nipples  after  every  nursing  with  absorbent 
cotton,  warm  water,  and  Castile  soap ;  by  cautioning  nurse 
and  patient  against  handling  the  breasts  with  fingers  not  asep- 
tic, and  by  smearing  the  skin   of  the  nipples  and  that  of  sur- 


Fig.  23b.— The  Murphy  breast-binder. 

rounding  parts  with  sweet-oil  after  every  washing,  applied  by 
a  piece  of  clean  linen  or  a  pledget  of  fresh  absorbent  cotton. 
There  is  another  point  in  the  management  of  the  breasts,  which, 
if  it  does  not  aid  in  preventing  so  serious  a  disturbance  as  mam- 
mary abscess,  does  increase  the  patient's  comfort  by  relieving  the 
feeling  of  distention  and  weight  whicli  is  experienced  during  the 
first  few  days  of  lactation.  This  is  the  adjustment  of  a  suitable 
mammary  binder.  The  Muqjhy  binder  or  its  modification  by 
Cooke  is  best  for  this  purpose  (Figs.  235  and  236). 

The  Child. — While    devoting   careful   attention  to  the  man- 


374  LABOR  AND   THE  PUERPERIUM. 

agement  of  a  woman  after  confinement,  the  physician  must  not 
forget  that  he  has  another  patient  on  his  hands,  of  almost  equal 
importance, — the  infant.  Fortunately,  the  management  of  a 
healthy  infant  is  easy.  If  a  few  common-sense  rules  are  observed, 
nature  does  the  rest.  The  management  of  the  new-born  child 
consists  simply  in  seeing  that  food  is  administered  at  proper  and 
regular  intervals,  that  attention  is  paid  to  bodily  cleanliness,  and 
that  ample  opportunity  is  afforded  for  an  almost  unhmited  amount 
of  sleep;  with  ordinary  precautions  in  regard  to  warmth.  The 
proper  interval  between  the  nursing  should  be  two  hours  during  the 
day,  four  to  five  hours  in  the  night.  If  the  child  is  taught  regular 
habits  in  this  respect,  the  burden  of  its  care-takers  is  immensely 
lightened.  The  infant  arouses  itself  and  is  ready  for  nursing 
at  the  proper  feeding-time,  and  in  the  intervals  sleeps  peace- 
fully. Regularity  in  nursing  is  of  importance,  further,  from  its 
favorable  influence  upon  the  constitution  of  the  milk.  Too 
frequent  nursing  results  in  a  concentrated  milk,  which  is  difficult 
to  digest.  Too  infrequent  nursing  results  in  a  watery  milk, 
which  is  not  nutritious.  If  the  infant  is  allowed  to  be  irregular, 
in  the  hours  for  feeding,  bathing,  and  sleeping,  it  grows  fretful, 
wakeful,  and  capricious  in  its  appetite.  A  word  of  caution  is 
necessary  about  the  infant's  bath.  The  temperature  of  the  water 
should  be  about  90°  ;  certainly  not  much  higher,  nor,  on  the 
other  hand,  too  low.  Nurses  are  often  extraordinarily  insensi- 
tive to  hot  water.  The  temperature  of  the  bath,  therefore,  should 
not  be  tested  by  their  hands,  but  by  a  bath-thermometer.  The 
bath  should  be  given  about  midday,  in  the  warmest  part  of  the 
room,  preferably  in  front  of  an  open  fire. 

There  are  many  apparently  small,  but  really  important,  details 
in  the  preparation  for  and  management  of  labor  and  the  puer- 
perium,  which  might  easily  be  forgotten.  It  is  convenient,  there- 
fore, to  give  patients  and  nurses  a  printed  list  of  instructions. 

DIRECTIONS  FOR  THE  MOTHER. 

Send  a  specimen  of  urine  (mixed  night  and  morning),  about  four 
ounces,  every  two  weeks  until  the  last  month,  then  every  week. 
Report  at  once  scanty  urination,  severe  headache,  swelling  of  the  feet 
or  face. 

Have  ready  for  the  labor:  towels,  ether  (one-half  pound),  brandy 
(two  ounces),  vinegar  (four  ounces)  ;  four  ounces  tincture  of  green 
soap;  a  bottle  of  antiseptic  tablets  (corrosive  sublimate);  a  large, 
coarse,  new  sponge  ;  a  skein  of  bobbin  ;  a  fountain  syringe  ;  bed-pan; 
new,  soft-rubber  catheter  ;  a  small  package  of  absorbent  cotton  ;  a 
one-ounce  bottle  of  carbolized  vaselin  ;  two  yards  unbleached  muslin 
(for  binder);  a  one-pound  package  of  salicylated  cotton;  five  yards 
of  carbolized  gauze  ;  eight  yards  of  nursery  cloth. 


THE   PUERPERAL    STATE.  .375 

The  last  is  to  be  boiled  for  half  an  hour  in  clothes-boiler,  dried 
thoroughly,  pinned  up  in  a  clean  sheet,  and  put  away  out  of  the  dust. 
A  mackintosh  or  rubber  cloth  is  necessary  to  protect  the  mattress ; 
two  yards  of  rubber  cloth,  one  yard  wide,  is  sufficient.  Prescription 
No.  I  Ms  to  be  procured  about  four  weeks  before  expected  confinement. 
It  is  to  be  applied  to  the  nipples,  night  and  morning,  with  absorbent 
cotton.  Prescription  No.  2  2  is  to  be  obtained  about  a  week  before- 
hand and  kept  in  readiness. 

Instead  of  providing  these  articles  separately,  a  complete  outfit 
for  labor,  sterilized,  put  up  in  a  closed  package  or  box,  may  be  ordered. 
The  author  recommends  the  outfit  described  in  the  appended  Hst. 

Two  sterilized  bed  pads  (30  ins.  Fluid  extract  ergot. 

square).  One  hundred   grams    chloroform 
Two  sterilized  mull   binders   (18  (Squibb's). 

ins.  wide).  One  hundred  grams  ether. 

Six  sterilized  towels.  Boric  acid,  powdered. 

Stocking  drawers,  sterilized.  Bichloride  tablets. 

Ten  yards  sterilized  gauze.  Talcum  powder. 

Five  yards  carbolized  gauze.  Four  quart  sterilized  douche  bag 

One    pound    package    salicylated  .  with  glass  nozzle. 

cotton.  Douche  pan,  sterilized. 

One    pound   sterilized    absorbent  Two  agate  basins,  sterilized. 

cotton  (^ half  pounds).  Bath  thermometer. 

Rubber  sheet  i  yard  X  i/^  yards,  Sterilized  nail  brush. 

sterilized.  Safety  pins. 

Rubber  sheet  i^^  yards  X  2  yards.  Sterilized  tape. 

sterilized.  Sterilized  soft  rubber  catheter. 

Two  tubes  sterilized  petrolatum.  Sterilized  glass  catheter. 

One  tube  K-Y  lubricating  jelly.  One  pair  sterilized  rubber  gloves 
Tincture  green  soap.  No.  73^. 

Baey-clothes. 

Four  to  six  dozen  diapers. 

Four  to  six  pairs  knit  (woolen)  socks. 

Three  to  four  shirts  (woolen). 

Four  flannel  night-skirts.        ")  *  n    1  •  .   .    -u         j       -.i.       •  .   •     .     j 
,,        ,        i-,  f  All  skirts  to  be  made  with  waists  instead 


night-skirts.        ^  .  n    1  •  ^   ..    1 
,  ^     1  .  ,  f  All  skirts  to  1 

aay-skirts.  >  r  v      j 

\^-i    A        1  •  *     t        of  bands, 
vhite  day-skirts.  J 


Four  to  six  white  day-skirts. 
Six  to  ten  slips. 

"        "     dresses. 
Material  for  four  or  five  flannel  bands  (45-  to  50-cent  flannel). 
Soft  pillow  (good  size,  14  x  18  inches). 

1  R.     Glycerol  of  tannin, 

Aqua, ^3.,  ^j 

01.  rosae, gtt.  ij. 

2R.     Ext.  ergot,  fld., f^j. 


37^  LABOR  AND  THE  PUERPERIUM. 

Soft  pillow  covers. 

Knit  wrapping  blankets. 

Sacques,  wrappers,  bibs,  caps,  blankets,  veils,  etc. 


Baby's  Basket. 

Large  and  small  safety-pins. 

Talcum  powder  (box  and  puff). 

Fine,  soft  sponge. 

Soft  brush  (for  hair). 

Castile  soap. 

Cold  cream. 

Alcohol  for  rubbing  child. 

Blunt  scissors  for  nails,  etc. 

Old  linen  for  cleaning  mouth. 

Soft  towels  for  bath. 

Bath-blanket. 

Wooden  forms  for  drying  socks. 

DIRECTIONS  FOR  THE  NURSE. 

Give  rectal  enema  as  soon  as  pains  begin  (pint  of  soapsuds,  dram 
of  turpentine).  Wash  the  external  genitals  thoroughly  with  soap  and 
warm  water.  As  soon  as  labor  begins,  fill  three  pitchers  with  water 
that  has  been  boiling  for  half  an  hour;  tie  clean  towels  over  their 
tops.  This  water  is  to  be  used  for  all  purposes  about  the  patient  and 
for  making  the  antiseptic  solutions. 

No  vaginal  injection  to  be  given  unless  ordered. 

Take  the  temperature  three  times  a  day, — morning,  noon,  and 
evening. 

Place  pad  of  nursery  cloth  under  patient ;  change  it  when  soiled. 
Occlusive  bandage  to  be  made  up  of  salicylated  cotton  and  carbolized 
gauze,  with  sterile  hands,  and  to  be  changed,  for  the  first  five  days, 
every  four  hours. 

The  external  genitals  to  be  washed  off  four  or  five  times  a  day 
with  warm  corrosive  sublimate  solution,  i  :  4000,  made  up  with  boiled 
water.      Use  absorbent  cotton  for  this  purpose. 

If,  at  the  end  of  twelve  hours,  the  bladder  can  not  be  emptied 
naturally,  use  a  catheter.  Afterward,  if  necessary,  catheterize  patient 
three  times  a  day. 

The  patient  is  to  lie  on  her  back  ;  she  may  be  moved  from  one 
side  of  the  bed  to  the  other  several  times  a  day  ;  her  limbs  may  be 
rubbed  with  alcohol  and  water  or  bathing-whisky  once  a  day. 

The  nurse's  hands  must  be  protected  by  sterile  rubber 
gloves  before  catheterizing  the  patient,  cleansing  the  genitals  or 
breasts. 

Diet. — First  48   hours. — Milk  (1^   to   2    pints  a  day),  gruel, 

soup,  one  cup  of  tea  a  day,  toast  and 
butter. 


THE  PUERPERAL  STATE.  377 

Second  48  hours. — Milk    toast,    poached    eggs,   porridge, 
soup,  cornstarch,  tapioca, wine-jelly, 
small  raw  or  stewed  oysters,  one  cup 
of  coffee  or  tea  a  day. 
Third  48  hours. — Soup,  white  meat  of  fowl,  mashed  pota- 
toes, beets,  in  addition  to  above. 
After  sixth  day,  return  cautiously  to  ordinary  diet, — that 
is,  three  meals  a  day,  meat  at  one  of  them,  of  an  easily 
digested  character, — white  meat  of  fowl,  tender]oin  of 
beef,  etc. , — and  a  glass  of  milk  at  least  three  times  a 
day,  between  meals  and  before  going  to  sleep  at  night ; 
also  a  glass  in  the  middle  of  the  night. 
Child. — After  being  well  rubbed  with  sweet-oil,  the  child  is  to  be 
washed  on  the  nurse's  lap.    The  bath-tub  may  be  used 
by  the  end  of  the  first  week.    Water  not  over  100°  F. 
The  cord  is  to  be  dressed  with  salicylated  cotton.     Ob- 
serve carefully  for  bleeding.     A  good  dusting-powder 
for  the  navel  is  salicylic  acid  i  part,  starch  5  parts. 
The  child  should  be  bathed  daily,  about  midday,  in  the 
warmest  part  of  the  room.   Use  Castile  soap  and  a  soft 
sponge  ;  avoid  the  eyes. 
Diapers   changed    often    enough.       For    chafe,   use    cold 
cream  and  talcum  powder. 
Nursing. — The  child  is  to  be  put  to  the  breast  every  four  hours 
for  the  first  two  days.     No  other  food  is  to  be  given  if.     After  the  second 
day  it  should  be  nursed  every  two  hours,  from  7  a.  m.  to  9  p.  m.,  and 
twice  during  the   night  (i  a.  m.  and  5  a.  m.).      After  every  nursing 
the  nipples  are  to  be  carefully  dried  and   then   smeared  with  a  little 
sweet-oil  for  the  first  week  or  two,   applied  with   fresh  pledgets    of 
absorbent  cotton. 

The   Final   Examination  at  the   End  of  the  Puerperium. — 

The  recently  delivered  woman  should  be  subjected  to  three  careful 
exanainatiGns:  The  first  shortly  after  labor,  or  as  soon  as  it  is 
convenient,  to  detect  the  injuries  of  child-birth;  the  second  before 
she  leaves  her  room,  to  determine  the  position  of  the  uterus ; 
and  the  third  at  the  end  of  si.x  weeks  after  deliver)-.  The 
final  examination  should  be  conducted  in  a  methodical  manner, 
as  follows : 

The  Inspection  of  the  Vulva. — As  a  woman  lies  on  an  exam- 
ining table  or  across  the  bed  with  her  thighs  separated,  the  labia 
majora  should  be  in  close  appo-sition,  closing  the  vulvar  orifice 
and  concealing  the  vaginal  entrance.  A  gaping  vulvar  orifice 
and  vaeinal  introitus  indicate  subinvolution  of  the  vagina,  over- 
stretching  of  the  tissues,  and  injury  of  the  perineal  center  or 
body. 

By  placing  the  thumbs  on  either  side  of  the  labia  and  stretch- 
ing them  apart  a  view  of  the  lower  third  of  the  vaginal  canal  is 


37^ 


LABOR  AND  THE  PUERPERIUM. 


Fig.  237. — Perfect  preservation  of  the  vulvar  orifice  and  pelvic  floor  in  a  primipara, 
six  weeks  after  labor. 


Fig.  238. — Gaping  vulvar  orifice  from  injury  to  the  perineal  body,  retract'ion  of 
the  ends  of  the  transversus  perinei  and  bulbo-cavernosus  muscle,  overstretching  and 
subinvolution  of  the  vagina. 


THE  PUERPERAL  STATE. 


379 


Fig.    239. —  Gaping    vulvar    orifice,  Fig.    240. — Gaping    vulvar    orifice 

injury  of  urogenital  trigonum  muscle,  and       with    rectocele    and    cystocele    from    a 
prolapse  of  lower  anterior  vaginal  wall.  former  labor. 


l"ig.    241. — Com|jlete  tear  of  the  peri- 
neum directly  after  labor. 


Fig.  242. — Same  patient  six 
weeks  later,  before  operation,  which 
had  been  postponed  on  account  of  al- 
buminuria and  infection. 


38o 


LABOR  AND  THE  PUERPERIUM. 


obtained;  injuries  in  the  posterior  sulci  to  the  levatores  ani  mus- 
cles are  visible;  lacerations  of  the  anterior  sulci  manifest  them- 
selves by  a  dropping  of  the  lower  anterior  vaginal  wall  downward 
and  forward,  making  a  pouch  of  mucous  membrane  filling  the 
distended  vaginal  entrance.  This  is  the  injury  which  later,  if 
not  repaired,  results  in  cystocele. 

If  there  is  a  complete  tear  of  the  perineum  through  the 
sphincter,  it  should  immediately  be  detected  on  inspection,  or 
certainly  when  the  labia  are  separated.  If  there  is  any  doubt 
about  it,  the  forefinger  of  the  left  hand,  protected  by  a  finger- 
cot,  in  the  rectum,  and  the  thumb  in  the  vagina  determine  the 
thickness  of  the  tissues  between  the  two. 


Fig.  243. — Complete  tear  of  the  perineum  six  weeks  after  labor;  sphincter  muscle 
masked  by  large  hemorrhoidal  vein. 


The  Digital  Examination  of  the  Vagina  (Indagation). — First 
injury  and  retraction  of  the  transversus  perinei  muscles  is  detected 
by  the  tip  of  the  forefinger  as  shown  in  Fig.  244.  Next,  the  in- 
tegrity of  the  levatores  ani  muscles  is  tested  as  follows:  The  fore- 
finger of  the  left  hand  is  inserted  to  the  second  joint;  pressure  is 
made  in  each  posterior  sulcus  downward  and  outward  toward  the 
tuber  ischii;  if  the  muscle  is  lacerated,  the  finger  sinks  into  a  deep 
cleft  almost  or  quite  to  the  bony  pelvic  wall.  The  forefinger  is 
then  swept  over  the  posterior  vaginal  wall  from  one  descending 
ramus  of  the  pubis  to  the  other;  if  the  levator  ani  is  injured  on 
either  side,  the  cleft  in  it  is  plainly  felt.     Both  forefingers  are  in- 


THE   PUERPERAL    STATE. 


381 


Fig.  244. — Palpation  of  pouch  due  to  licLruion   diid   ntiaction  of  the  transversus 
perinei  muscle:    a,  Photogiaph  from  nature,  b^  diagrammatic  sketch. 


Fig.  245. — Testing  the  levator  ani  muscle  in  the  right  posterior  vaginal  sulcus.     In 
this  case  there  was  a  deep  tear. 


382  LABOR  AND    THE   PUERPERIVM. 

serted  in  the  posterior  sulci;  pressure  is  made  outward  and  down- 
ward. The  levator  ani  is  palpated  between  the  thumb  and  fore- 
finger; one  being  inside  the  vagina,  the  other  upon  the  labium. 
Next,  the  integrity  of  the  urogenital  trigonum  muscle  ^  and  fascia  is 
tested  by  pressing  the  forefinger  into  each  anterior  sulcus  upward 
against  the  lower  edge  of  the  pubic  bone.  A  muscular  cushion  is 
felt  in  the  normal  case.  If  there  is  a  submucous  laceration  of  the 
muscle,  the  finger  comes  in  close  contact  with  the  sharp  edge  of  the 
bone.  The  left  anterior  sulcus  is  usually  the  site  of  injury,  as 
the  long  diameter  of  the  fetal  skull  almost  always  lies  in  the 
right  oblique  diameter  of  the  maternal  pelvis.  The  finger  is 
now  inserted  more  deeply  in  the  vagina  to  feel  the  cervix  in  order 
to  detect  the  kind  and  degree  of  injury  it  may  have  suffered. 
The  direction  of  the  cervix  is  of  no  importance  in  diagnosticat- 
ing uterine  position  ;  it  may  look  forward  in  anteflexion  and 
backward  in  retroflexion. 

The  position  of  the  uterus  is  next  investigated — of  all  single 
items  of  information  in  this  examination,  the  most  important.  A 
combined  examination  is  necessary.  If  the  corpus  uteri  can  be 
grasped  between  the  finger  or  fingers  in  the  anterior  vaginal 
vault  and  the  fingers  of  the  other  hand  upon  the  hypogastrium, 
and  the  fundus  points  sufficiently  far  forward  for  the  weight  of 
the  intra-abdominal  contents  to  rest  upon  the  posterior  uterine 
wall,  the  uterus  is  in  satisfactory  position.  If  it  is  impossible  to 
take  this  bimanual  grip  of  the  uterus,  the  internal  fingers  are 
shifted  to  the  posterior  vaginal  vault,  and  if  there  is  a  retro- 
flexion, the  corpus  uteri  is  easily  traced  backward  toward  the 
sacrum  and  the  angle  of  flexion  is  plainly  felt  in  the  lower  uterine 
segment.  Pressure  from  above  through  the  abdominal  wall 
facilitates  the  palpation  of  the  retroflexed  uterus. 

During  the  bimanual  examination  the  size  and  consistency  of 
the  uterus  are  noted  to  determine  the  degree  of  involution. 

Finally,  the  broad  ligaments,  the  tubes  and  ovaries,  and  the 
utero-sacral  ligaments  are  palpated  by  a  combined  examination 
to  detect  inflammatory  swelling,  displacements,  fixation,  and  peri- 
toneal or  cellulitic  exudate. 

The  specular  examination  of  the  vagina  and  cervix  follows  the 
digital  examination  to  detect  ulcerations  of  the  vagina  or  injuries 
in  its  upper  part,  and  particularly  to  determine  the  kind  and 
degree  of  injuries  to  the  cervix,  the  existence  of  e version  and 
erosion  of  the  hps.     A  bivalve  speculum  (Collins)  is  most  con- 

1  For  the  best  description  of  this  muscle  the  student  is  referred  to  Waldeyer's 
"  Das  Becken."  It  runs  across  the  anterior  vaginal  wall  from  one  ischiopubic  junc- 
tion to  the  other.  It  is  the  only  muscle  actually  inserted  into  the  vagina,  and  is  the 
strongest  support  of  the  lower  anterior  vaginal  wall  ;  its  laceration,  which  frequently 
occurs  in  labor,  is  the  first  step  in  the  formation  of  a  cystocele. 


THE   PUERPERAL    STATE.  383 


Fig.  246. — Examining  the  position  of  the  uterus. 


Fig.   247. — Protrusion  between  gaping  recti  muscles  of  coils  of  intestines,  in  which 
peristalsis  could  be  seen. 


384 


LABOR  AND    THE   PUERPERIUM. 


venient  to  examine  the  cervix.     The  author's   ^'leleton  bivalve 
speculum  gives  the  best  view  of  the  vaginal  walls. 


Fig.  248. — Pyramidal  elevation  of  the  abdomen  when  the  woman  strained. 


Fig.  249. — Retraction  instead  of  protrusion  of  the  abdominal  wall  between  the  recti 
muscles  when  the  patient  attempts  to  rise  to  a  sitting  posture. 


The  abdominal  wall  is  palpated  and  inspected  to  test  its  tonicity, 
and  particularly  to  detect  a  diastasis  of  the  recti  muscles.     The 


THE   PUERPERAL    STATE. 


385 


separation  of  the  latter  is  measured  by  sinking  the  outspread  fin- 
ger-tips o  ne  hand  crosswise  between  the  muscles.  If  there 
is  doubt  as  to  the  degree  of  separation,  while  the  fingers  are  held 
in  position,  the  physician  helps  the  patient  to  rise  to  a  sitting 
posture  by  grasping  her  hand.     In  a  normal  case  the  muscles  are 


Fig.  250. — Testing  the  separation  of  the  recti  muscles. 


approximated  as  the  patient  rises.  If  there  is  diastasis,  the  degree 
of  separation  is  evident,  as  the  muscles  are  clearly  outlined  when 
they  contract.  By  inspection,  protrusion  of  intestines  can  be  seen 
in  extreme  cases.  If  the  woman  strains,  the  abdominal  \\?\\  is 
thrown  outward  in  a  wedge  shape  between  the  muscles.  Rarely 
it  is  retracted  instead  of  protruded. 

The  kidneys  are  palpated  to  determine  their  position  and  mobil- 
ity. The  woman  sits  bolt  upright,  her  back  and  head  supported, 
her  arms  hanging  down  limp  alongside  of  her,  and  all  her  muscles 
relaxed  as  much  as  possible.  The  outspread  fingers  of  the  ph\-si- 
cian's  hands  grasp  the  kidney  through  the  anterior  and  the  jioste- 
rior  abdominal  walls.  If  the  kidney  is  in  good  position,  the  fingers 
of  the  anterior  hand  must  be  inserted  under  the  floating  ribs. 
Another  method  is  to  examine  the  patient  on  her  feet,  the  trunk 
flexed  and  the  arms  supported  on  the  back  of  a  chair  (k'ig.  251  ). 

The  coccyx  is  examined     to    detect    injury    ot    its    jcMiits    as 
illustrated  in  Fig.  252,  the  woman  being  placed  in  Sims'  ])()sition 
and  the  physician's  forefinger  protected  by  a  rubber  finger-cot. 
25 


386 


LABOR  AND    THE    PUERPERIUM. 


Fig.  251. — Palpation  of  a  floating  kidney  in  the  erect  posture. 


Fig.  252. — Examination  of  the  coccyx. 


•   THE   PUERPERAL    STATE.  387 

It  is  only  by  such  a  methodical  and  thorough  examination 
that  the  physician  avoids  overlooking  the  ill  consequences  of 
labor.  The  invalidism  of  women  following  child-birth  could  be 
enormously  reduced,  a  reproach  to  medicine  could  be  removed, 
if  this  plan  were  uniforml\^  adopted. 

There  is  no  valid  excuse  for  a  rectocele,  injured  cervix  with  all 
its  consequences,  including  cancer,  cystocele,  uterine  displacements 
of  puerperal  origin,  including  prolapse,  subinvolution,  and  endome- 
tritis following  child-birth,  coccygodynia  from  a  ruptured  joint  in 
labor,  pendulous  belly  with  ptosis  of  the  abdominal  viscera  from 
a  relaxed  abdominal  wall,  and  diastasis  of  the  recti  muscles.  All 
the  injuries  of  child-birth,  including  those  of  the  cervix  and 
of  the  anterior  vaginal  wall,  can  be  successfully  repaired  during  the 
puerperium  by  an  intermediate  or  by  a  secondary  operation,  in- 
stead of  allowing  the  woman  to  endure  years  of  suffering  and 
invalidism  with  such  impairment  of  physical  and  nervous  strength 
that  she  can  never  be  restored  to  her  original  health. 

Every  one  of  the  conditions  enumerated  above  is  amenable 
to  appropriate  treatment,  and  none  of  them  should  be  allowed  to 
become  chronic. 


PART  III. 
THE  MECHANISM  OF  LABOR* 


The  mechanism  1  of  labor  is  the  manner  in  which  a  fetus  and 
its  appendages  traverse  the  birth-canal  and  are  expelled.  It 
takes  into  account  the  complicated  structure  of  the  maternal 
and  fetal  parts,  considering  their  movements  and  the  mechanisms 
of  their  motions. 

It  is  necessary  to  define,  further,  certain  terms  that  will  be  used 
constantly  in  the  study  of  the  mechanism  of  labor. 

By  presentation  is  meant  that  part  of  the  fetal  body  which 
presents  itself  to  the  examining  finger  in  the  center  of  the  plane 
of  the  superior  strait. 

The  term  position  may  be  applied  to  the  position  of  the 
child  in  Jitero,  whether  it  is  longitudinal,  oblique,  or  transverse  ; 
or,  in  another  sense,  it  is  the  varying  relations  which  the  present- 
ing part  of  the  fetus  bears  to  the  surrounding  maternal  structures 
at  the  plane  of  the  superior  strait. 

The  presentation  and  position  of  the  fetus  are  determined  by 
abdominal  palpation,  by  auscultation,  and  by  vaginal  exami- 
nation. 

Abdominal  Palpation. — For  this  kind  of  obstetrical  exami- 
nation the  woman  should  be  placed  on  her  back,  with  the 
abdomen  exposed.  The  examiner,  standing  to  one  side  of  the 
patient,  by  a  series  of  stroking,  patting,  and  rubbing  motions 
with  his  hands,  determines  the  height  of  the  fundus  uteri,  the 
tension  of  the  abdominal  walls,  the  irritability  of  the  uterus,  the 
quantity  of  liquor  amnii,  the  size  of  the  fetus,  its  position,  and  its 
presentation.  It  has  been  claimed  that  in  favorable  cases  the 
placenta  can  be  felt,  and  that  its  position  can  thus  be  diagnosti- 
cated (Spencer).  It  is  further  asserted  that  if  the  greater  bulk 
of  the  uterus  is  anterior  to  the  insertion  of  the  tubes,  the  pla- 
centa is  anterior,  and  vice  versa  (Leopold). 

1  From  the  Greek  iir]xcLvrj,  contrivance,  machine  (from  root  /jf/xoc,  a  manner,  a 
way,  a  means). 

388 


ABDOMINAL   PALPATION. 


389 


The  Diagjwsis  of  Fetal  Position  and  Presentation  by  Abdomi- 
nal Palpation. — The  examiner  stands  alongside  the  patient, 
facing-  her  head;  the  tips  of  the  fingers  of  both  hands,  moving 
together  and  at  equal  distances  from  the  middle  line,  are  carried  up 
the  sides  of  the  abdomen  by  a  series  of  tapping  movements  ;  and 
upon  one  side  (for  example,  the  left,  in  the  L.  O.  A.  position)  is 


Fig.  253. — Abdominal  palpation  :   locating  the  fetal  back. 


Fig.  254. — Abdominal  palpation  :   finding  the  lower  extremities  of  the  fetus. 

noticed  a  firm,  broad,  even  sense  of  resistance,  contrasting  with  the 
cystic,  tumor-like  sensation  of  the  other  side,  with  the  occasional 
encounter  of  firm,  irregular  bodies, — the  fetal  extremities. 

This  firm,  broad,  even  resi.stance  is  produced  by  the  fetal 
back,  and,  to  confirm  this  fact,  the  extremities  are  felt  for  by 
a  rubbing   motion   with    one  outstretched  hand  on  the  opposite 


390 


THE   MECHANISM  OF  LABOR. 


side.  They  are  felt  as  cylindrical,  irregular  bodies,  slipping  away 
from  the  hand,  and  changing  their  position  from  time  to  time. 
Having  located  the  back  and  the  extremities,  the  portion  of  the 
fetal  ellipse  presenting  at  the  superior  strait  is  next  ascertained. 
The  examiner  now  faces  the  woman's  feet,  and,  with  the  out- 
stretched hands,  the  fingers  parallel  with  and  the  jniddle  finger 
over  the  center  of  Poupart's  ligament,  on  either  side,  the  fingers 
dip  down  beneath  the  ligament  into  the  pelvic  cavity.  If  the 
head  is  presenting,  it  is  felt  as  a  hard,  regular,  round  body, 
the  greater  mass  of  the  occiput,  the  sharp  point  of  the  chin, 
and  the  groove  between  occiput  and  back  being  often  distin- 
guishable. At  the  same  time,  the  density  of  the  head,  its  com- 
pressibility, its  approximate  size,  and  its  relative  size  to  the 
pelvis  may  be  learned. 


Fig.  255. — Abdominal  palpation  :   locating  the  fetal  head. 


By  auscultation  the  fetal  heart-sounds  are  located,  and  their 
rate  and  intensity  are  noted.  The  uterine  bruit  and  the  funic 
souffle  are  often  heard.  The  former  is  a  low-pitched  musical 
murmur  synchronous  with  the  maternal  heart-beat.  The  latter 
is  a  high-pitched  whistling  murmur  synchronous  with  the  fetal 
heart-beat.  The  position  on  the  abdomen  at  which  the  fetal 
heart-sounds  are  heard  with  greatest  intensity  is  of  diagnostic 
value  in  confirming  the  find,  by  abdominal  palpation,  as  to  posi- 
tion and  presentation. 

By  vaginal  examination  the  finger  detects  the  varying  por- 
tions of  the  fetal  body  which  may  present  at  the  superior  strait, 
as  the  cranium,  the  face,  the  shoulder,  the  buttocks,  the  knees, 
feet,  and,  exceptionally,  the  elbow  or  hand. 

The  position  of  the  fetus  in  iitcro  is  longitudinal  in  99^  per 
cent,  of  all  cases.  The  cephalic  extremity  presents  in  about 
95^  per  cent.,  95  per  cent,  being  vertex  presentations.  In 
about  one-half  of  i  per  cent,  of  cases  the  face  presents  ;  the 
brow  very  rarely.      In   about  3  per  cent,  of  all  cases  the  breech 


ABDOMINAL    PALPATION.  39 1 

presents,  and  in  about  one-half  of  i  per  cent,  the  fetus  occupies 
a  transverse  position  /;/  iitero. 

An  explanation  of  the  great  frequency  of  cephalic  presentations 

is  found  in  a  voluntary  assumption  of  that  position  by  the  fetus, 
because  it  affords  it  the  greatest  degree  of  comfort  and  the  best 
opportunity  for  growth  and  development,  the  largest  room  being 
found  in  the  fundus  uteri  for  the  lower  extremities,  which  are 
freely  moved  and  exercised.  ^ 

An  explanation  of  the  great  frequency  of  presentations  of  the 
vertex  is  afforded  by  the  mechanical  arrangement  of  the  connec- 
tion between  fetal  head  and  body,  diagram- 
matically  represented  by  two  bars  attached 
to  each  other, — that  representing  the  head 
joined  to  that  representing  the  spinal  col- 
umn, not  at  its  middle,  but  at  a  point 
nearer  one  end  of  the  bar  (Fig.  256).  An 
equal  force  exerted  upon  both  ends  of 
the   lever  represented    by  the  child's  head     .       F'g-  256.— Diagram 

•n  li     •        J.1  i.  n       •  c     i.'u         illustrating;   the   cause  of 

will   result    ni    the  greater    flexion  of    the     ^^^  frequency  of  vertex 
longer   bar,    which  is   that   portion  of  the     presentations. 
fetal  skull  in  front  of  spinal  column. 

The  positions  of  the  various  presentations  are  named  by  the 
relationship  which  the  most  prominent  anatomical  feature  of  the 
presenting  part  bears  to  the  acetabula  or  to  the  sacro-iliac  junc- 
tions of  the  maternal  pelvis.     They  are,  therefore,  four  in  number. 

Positions  of  Vertex  Presentations. —  i.  L.  O.  A.,  left  occipito- 
anterior, the  occiput  looking  to  the  left  acetabulum.  2.  R.  O.  A., 
right  occipito-anterior.  3.  R.  O.  P.,  right  occipitoposterior, 
'the  occiput  looking  to  the  right  sacro-iliac  joint.  4.  L.  O.  P.,  left 
occipitoposterior.  Of  all  vertex  presentations  about  seventy  per 
cent,  are  L.  O.  A.,  thirty  per  cent.  R.  O.  P.  The  long  axis  of 
the  fetal  skull  very  rarely  lies  in  the  left  oblique  diameter  of  the 
maternal  pelvis. 

Explanation  of  the  Frequency  of  L.  O.  A.  and  R.  O,  P. — The 
position  of  the  rectum  shortens  the  left  oblique  diameter  of  the 
pelvis  ;  therefore  the  long  diameter  of  the  head,  seekiiig  the 
direction  of  least  resistance,  adjusts  itself  in  the  right  oblique 

1  It  is  probable  that  other  factors  often  enter  into  the  assumption  of  a  cephalic 
presentation  by  the  fetus.  The  fact  that  the  cephalic  e.\tremity  is  the  heavier,  and  so 
falls  toward  the  pelvis  as  the  woman  stands  erect,  and  tlie  growth  of  the  uterus  in  a 
perpendicular  ratlier  than  a  lateral  direction,  tbrcing  the  long  axis  of  the  fetus  to 
coincide  with  the  long  axis  of  the  uterus,  are  no  doubt  instrumental  in  determining  a 
cephalic  rather  than  a  pelvic  presentation  ;  but  if  one  accepts  this  explanation  unre- 
servedly, he  could  not  explain  a  breech  presentation  at  all,  nor  could  he  account  for 
the  return  of  a  fetus  to  a  breech  presentation  after  it  had  been  turned  by  external 
version.  Sir  James  Y.  Simpson's  theory,  therefore,  given  in  the  text  is,  on  the  whole, 
the  most  satisfactory. 


392 


THE   MECHANISM   OF  LABOR. 


diameter  of  the  pelvis  and  the  projection  of  the  lumbar  spinal 
column,  to  which  the  fetus  by  choice  adapts  its  anterior  concave 
surface,  usually  results  in  the  back  being  turned  forward  and 
tilted  a  little  toward  the  right,  because  of  the  usual  right  lateral 
version  of  the  pregnant  uterus.  Thus,  the  left  occipito-anterior 
position  of  the  vertex  is  the  commonest  position  in  labor. 
Should  the  child's  back  be  directed  to  the  right,  the  occiput  is 
turned  posteriorly,  because  the  chin  would  be  pushed  forward 
by  the  sigmoid  flexure  and  rectum,  this  being  a  stronger  force  in 
the  arrangement  of  the  head  than  the  child's  inclination  to  adapt 
its  concave  abdominal  surface  to  the  convex  surface  of  the 
maternal  lumbar  spine. 


THE  FORCES  INVOLVED  IN  THE  MECHANISM  OF  LABOR. 

There  are  certain  forces    operative  in  every  labor  irrespec- 
tive of  fetal   presentation,  and  position.      These   are   the  forces 

of  expulsion  contributed  by 
the  uterine  muscle  and  the 
abdominal  muscles,  and  the 
forces  of  resistance  con- 
tributed by  the  lower  uterine 
segment,  the  cervix,  vagina, 
vulva,  the  pelvis,  and  the  fetal 
body. 

The  forces  of  expulsion  are 
furnished  by  a  great  part  of  the 
uterine  muscle  (the  upper  uter- 
ine segment)  and  by  the  mus- 
cular action  of  the  abdominal 
wall.  That  portion  of  the 
uterine  canal  which  must  be 
dilated  to  allow  the  escape  of 
the  fetus  is  called  the  lower  uter- 
me  segment.  Its  boundaries  are : 
above,  the  firm  attachment  of 
the  peritoneum  to  the  uterine 
wall,  and,  below,  the  internal 
OS.  That  portion  of  the  uter- 
ine wall  above  the  point  at 
which  the  dilatation  of  the  uterine  cavity  begins  is  called  the 
upper  uterine  segment ;  the  boundary-line  between  these  seg- 
ments, often  marked  by  a  perceptible  ridge,  especially  in  ob- 
structed labors,  is  called  the  contraction  ring,  or  the  ring  of 
Bandl. 


Fig.  257. — Diagram  showing  the 
diminution  of  the  upper  uterine  seg- 
ment and  the  expansion  of  the  lower 
segment  during  each  contraction. 


Plate  io. 


Fetal  skull  seen  (l)  from  the  side,  (2)  from  above,  (3)  from  behind,  and  (4)  from  in  front, 
showing  sutures,  fontanels,  and  diameters  (Dickinson). 


FORCES  INVOL  VED   EV  MECHANISM  OF  LABOR. 


393 


The  manner  in  which  the  uterine  muscle  exerts  its  force 
upon  the  fetal  body  is  by  a  diminution  of  the  intra-uterine  area. 
The  uterine  muscle  in  contraction  somewhat  increases  the  longi- 
tudinal diameter  of  the  uterus,  but  decidedly  diminishes  the 
transverse  and  anteroposterior  diameters.  The  contraction  of 
the  abdominal  muscles  likewise  diminishes  the  area  of  intra- 
abdominal space.  The  degree  of  force  exerted  by  the  combined 
action  of  uterine  and  abdominal  walls  has  been  estimated  to  be 
from  seventeen  to  fifty-five  pounds.  The  forces  of  resistance 
are  furnished  by  that  portion  of  the  parturient  tract  which 
must  be  dilated, — /.  c,  from  the  contraction  ring  to  the  vulva, 
including  the  lower  uterine  segment,  the  cervix,  the  vagina,  and 
the  vulva.  The  dilatation  of  the  cervix  is  effected,  if  the 
membranes  are  preserved,  by  the  displacement  of  the  most 
easily  displaceable  of  the  uterine  contents,  the  liquor  amnii,  in 


Fig.     258. — Diagram     illustrating  Fig.     259. — Diagram     illustrating 

alteration   in    shape   of  a   cross-section  the  alteration  m  the  shape  of  a  sagittal 

of  a  uterus  during  its  contractions.     The  section  of  the  uterus  during  its  contrac- 

heavy  line  represents  the  non-contracted,  tions.      The  heavy  line  represents  the 

the    dotted  line    the    contracted  uterus  non-contracted,  the  dotted  line  the  con- 

(compare  Fig.  259)  (Dickinson).  tracted  uterus  (Dickinson). 


the  direction  of  least  resistance, — throug-h  the  cervical  canal. 
A  pouch  of  the  membranes  insinuated  in  the  canal  subjects  the 
surrounding  ring  of  cervical  muscle  to  water-pressure,  equally 
exerted  in  all  directions,  but  felt  by  the  cervix  only  in  a  lateral 
or  horizontal  direction.  If  the  membranes  are  ruptured  and  the 
presenting  part  impinges  directly  on  the  cervix  and  lower  uterine 
segment,  the  former  is  subjected  to  a  lateral  pull  from  all  sides 
at  once,  as  the  presenting  part  pushes  from  above  downward. 
The  presenting  part,  moreover,  whatever  it  be,  is  somewhat  con- 
ical in  form,  and  subjects  the  cervix  to  a  lateral  push  as  it  is 
wedged  into  the  cervical  canal  (Fig.  260).  The  dilatation  of  the 
lower  uterine  segment  and  of  the  cervix  is  not,  however,  simply 
mechanical,  the  serous   infiltration  of  the   lymph-spaces  and   the 


394  THE   MECHANISM  OF  LABOR. 

separation  of  the  muscle-fibers  lessening  the  power  of  resistance 
gained  by  cohesion  of  muscle-bundles. 

The  dilatation  of  both  the  lower  uterine  segment  and  the  cer-^ 
vical  canal  is  also  assisted  by  the  longitudinal  muscle-fibers  in 
these  regions  drawing  the  cervix  up  over  the  presenting  part. 
Finally,  the  circular  muscle  of  the  cervix,  subjected  to  the  strain 
of  constant  push  and  pull,  becomes  fatigued  and,  at  length,  para- 
lyzed. Below  the  cervix  dilatation  is  effected  mainly  by  the 
mechanical  stretching  of  the  walls  of  the  birth-canal. 

The  bony  walls  of  the  pelvis,  in  a  normal  case,  only  offer  enough 
resistance  to  delay  the  progress  of  the  presenting  part  suffi- 
ciently to  insure  a  gradual  dilatation  of  the  soft,  resisting 
structures. 

The  Fetal  Body. — The  head  is  by  far  the  most  important 
anatomical  division  of  the  fetal  body  in  labor,  on  account  of  its 
bulk  and  density.  The  fetal  head  may  be  divided  into  the 
yielding  and  the  unyielding  portions.  The  former  consists  of 
the  cranium,  composed  of  the  two  frontal,  the  two  temporal,  the 


Fig.  260. — Diagrams  illustrating  the  lateral  "pull"  and  "push"  on  the  cervix. 

two  parietal,  and  the  occipital  bones.  These  bones  are  separated 
from  each  other  as  follows  :  The  two  frontals  by  the  frontal 
suture,  the  frontal  from  the  parietal  by  the  coronal  suture,  the 
two  parietal  by  the  sagittal  suture,  and  the  two  parietal  from 
the  occipital  by  the  lambdoidal  suture.  At  the  junction  of 
the  lambdoidal  and  the  sagittal  sutures  there  is  a  membranous 
space,  called  the  posterior  fontanel,  triangular  in  shape.  At  the 
junction  of  the  frontal,  coronal,  and  sagittal  sutures  there  is 
also  a  membranous  space,  called  the  anterior  fontanel,  kite- 
shaped,  and  larger  than  the  posterior  fontanel.  This  portion 
of  the  skull,  the  cranium,  yields  to  pressure,  and  is  reduced  in 
size  by  an  overlapping  of  the  bones. 

The  unyielding  portion  of  the  skull  comprises  the  face  and 
the  base  of  the  skull.  The  bones  of  this  region  are  fixed  and 
unyielding. 

A  transverse  vertical  section  of  the  skull  is  somewhat  wedge- 
shaped,  the  wedge  tapering  toward  the  neck.  A  longitudinal 
medial  section  is  distinctly  conical  in  form. 


MECHANISM  OF  PRESENTATIONS  AND   POSITIONS.      395 

Possible  Presentations  of  the  Head. —  Vertex. — By  this  term  is 
meant  that  conical  portion  of  the  skull  with  its  apex  at  the 
smaller  fontanel  and  its  base  at  the  planes  of  the  biparietal 
and  trachelobregmatic  diameters, — the  face ;  the  brozv ;  the 
Im'ger  fontanel ;  tlie  parietal  eminence  ;  the  ear.  / 

THE  MECHANISM  OF  THE  SEVERAL  PRESENTATIONS  AND 

POSITIONS. 

The  Mechanism  of  Labor  in  a  Vertex  Presentation  and  a 
Left  Occipito=anterior  Position. — It  is  convenient  to  begin  the 
study  of  each  presentation  with  a  consideration  of  its  diagnosis. 

Tlie  diagnosis  of  position  and  presentation  is  made  by  abdom- 
inal palpation,  auscultation,  and  vaginal   examination.     By  these 


Fig.  261. — Left  occipito-anterior  position  of  a  vertex  presentation. 

methods  of  examination  in  the  position  and  presentation  under 
discussion  the  fetal  back  is  found  to  the  left,  the  extremities  to 
the  right  and  above,  the  head  below  ;  the  heart-sounds  are  heard 
most  distinctly  about  an  inch  below  and  to  the  left  of  the  umbili- 
cus ;  the  examining  finger  in  the  vagina  detects  the  vertex  pre- 
senting, with  the  occiput  directed  toward  the  left  acetabulum  ;  the 
sagittal  suture  is  in  the  right  oblique  diameter  of  pelvis  ;  the 
smaller  fontanel,  recognized  by  the  junction  of  the  lambdoidal 
and  the  sagittal  sutures,  is  the  most  dependent  portion  of  the 
presenting  part ;  the  tip  of  the  occipital  bone  is  overlapped  by 
the  parietal  bones.  As  the  direction  or  axis  of  the  pelvic  canal 
diverges  from  that  of  the  uterine  cavity,  running,  at  first,  more 


396 


THE   MECHANISM   OF  LABOR. 


posteriorly,  there  is  usually  a  lateral  inclination  of  the  head  so 
that  the  sagittal  suture  is  posterior  to  the  normal  position  of 
the  oblique  diameter  of  the  pelvis,  and  one  parietal  bone  (the 
anterior)  is  deeper  in  the  pelvis  than  the  other  one. 

The  mechanism  of  labor  in  a  left  occipito-anterior  position 
of  a  vertex  presentation  may  be  taken  as  a  type  of  the  mechanism 
of  all  labors,  the  variations  in  the  process  im.posed  upon  it  by 


Fig.  262. — Vertex  presentation,  left  occipito-anterior  position. 


the  different  positions  and  presentations  of  the  fetus  being  readily 
understood  if  the  typical  mechanism  of  the  commonest  presenta- 
tion and  position  is  thoroughly  mastered. 

It  is  convenient  to  divide  the  mechanism  of  labor  into  a 
number  of  steps  or  acts,  as  follows  : 

First  Step. — Accommodation  of  the  size  of  the  fetal  skull  to 
the  size  of  the  pelvic  canal  by  flexion  ;  accommodation  of  the  shape 
of  the  fetal  skull  to  the  shape  of  the  pelvic  inlet  by  molding  ; 
accommodation  of  the  direction  of  the  head  to  the  direction  of 


MECHANISM    OF  PRESENTATIONS  AND   POSITIONS.      397 


the  pelvic  canal  by  lateral  inclination.  These  movements  occur 
prior  to  labor,  when  the  head  enters  the  pelvic  inlet  with  the 
subsidence  of  the  uterus. 


lr.-t«" 


— t' 
—I 


Fig.  263. — Genital  tract  with  fetus  removed,  showing  divergence  of  the  pelvic 
axis  from  that  of  the  uterine  cavity:  a,  a.  Membranes;  b,  b,  contraction  ring;  c,c, 
point  down  to  which  membranes  are  unseparated ;  </,  promontory  ;  e,  region  of  os 
internum  (above  which  fragments  of  decidua  are  found,  and  below  it  cervical  glands)  ; 
/j  bulging  of  wall  into  neck  of  fetus  ;  ,^^  g,  os  externum  ;  h,  pouch  of  Douglas  ; 
i,  posterior  vaginal  wall  (elongated  and  thinned)  ;  j,  rectum  ;  /',  stretched  anal  canal ; 
/,  placenta  ;  w,  uterovesical  peritoneum ;  ;/,  region  of  os  internum  (above  which 
fragments  of  membranes  are  found,  and  below  it  portions  of  cervical  glands)  ;  0,  lower 
limit  of  bladder;  /,  anterior  vaginal  wall  (not  elongated);  </.  urethra;  ;-,  vagina; 
s,  vulva;  /,  perineum  with  blood  extravasation  (Barbour  and  Webster). 

Second  Step.- — Further  flexion,  moldin^r,  and  accommodation 
of  the  head  to  the  pelvis  by  lateral  inclination,  when  labor-pains 
appear,  and  the  head  is  subjected  to  a  propulsive  force  and  to  the 
resistance  of  the  lower  uterine  segment,  the  cervix,  and  the  pelvic 
walls. 


398 


THE   MECHANISM   OF  LABOR. 


Third  Step. — Dilatation  of  the  lower  uterine  cavity  and  of  the 
cervical  canal. 

Fourth  Step. — Descent  of  the  head  to  the  pelvic  floor,  mainly 
by  an  extension  of  the  fetal  spine.  The  fetal  body,  as  a  whole, 
is  not  yet  propelled  along  the  birth-canal,  because,  during  a  pain 
and  while  the  head  is  obviously  descending  to  the  pelvic  floor, 
the  fundus  uteri  and  the  breech  do  not  sink  to  a  lower  level. 
On  the  contrary,  there  is  a  slight  elevation  of  the  fundus,   an 


Fig.    264. — The  descent  of  the  head  in  a  vertex  presentation,  left  occipito-anterior 

.  position. 


elongation  of  the  uterus,  and  the  distance  between  the  head  and 
the  breech  increases  during  a  uterine  contraction. 

Fifth  Step. — Anterior  rotation  of  the  occiput. 

TJie  Cause  of  Tliis  Moveinent. — The  most  dependent  portion 
of  the  head,  the  tip  of  the  occiput,  driven  through  the  funnel- 
shaped  parturient  canal,  first  strikes  the  resistance  of  the  upper  por- 
tion of  the  pelvic  floor,  which  is  represented  by  a  curved  line  or 
plane  running  inward,  downward,  and  forward.  These  directions 
are  imposed,  therefore,  upon  any  movable  body  impinging  upon 
the  pelvic  floor  and  impelled  by  a  force  from  above.  The  occiput 
can  only  travel  in  the  directions  named  by  a  rotary  movement 
of  the  head  upon  the  spine.  The  pelvic  canal  is  a  spiral  canal 
making;  half  a  turn  in  its  course.     The  wall  of  each  half  of  the 


MECHANISM  OF  PRESENTATIONS  AND  POSITIONS.      399 

pelvic  canal  might  be  represented  by  innumerable  spiral  lines 
crossing  one  another  from  behind  forward  and  from  before  back- 
ward. But  the  lines  running  from  behind  forward  are  much 
bolder  and  more  pronounced  in  their  curve  than  those  running 
from  before  backward  ;  hence,  any  body  encountering  the  re- 
sistance of  the  pelvic  wall  or  floor  is  impelled  to  take  a  direction 
by  preference  downward,  forward,  and  inward  ;  if,  however,  there 
should  be  an  insuperable  obstacle  to  movement  in  these  directions, 


Fig.  265. — The  descent  of  the  head  in  a  vertex  presentation,  left  occipito-anterior 

position. 

the  course  of  the  more  feebly  marked  lines  is  followed — namely, 
downward,  inward,  and  backward.  Anterior  rotation  of  the 
presenting  part  is  therefore  the  rule  ;  posterior  rotation,  even  from 
an  anterior  position,  is  the  exception,  but  is  possible. 

Sixth  Step. — Propulsion  and  extension  of  the  head  in  the 
direction  of  least  resistance  under  the  pubic  arch  until  it  is  deliv- 
ered, again  following  the  direction  of  the  lower  pelvic  floor, 
which  is  now  upward,  forward,  and  outward. 

Seventh  Step. — Restitution.  The  rotary  movement  of  the 
head,  previously  described,  is  not  followed  by  the  shoulders.  As 
the  former  escapes  from  the  vulva  with  the  sagittal  suture  running 


400 


THE   MECHANISM   OF  LABOR. 


J> 


Fig.  266. — The  rotation  of  the  head  being  completed,  its  propulsion  forward  and 

outward  begins. 


Fig.  267. — The  passage  of  the  head  over  the  perineum. 

anteroposteriorly.  the  neck  is  necessarily  twisted.     As  soon  as  the 
head  is  released  from  the  forces  which  compel  its  rotation,  it  imme- 


MECHANISM  OF  PRESENTATIONS  AND   POSITIONS.     4OI 

diately  resumes  its  natural  relationship  with  the  shoulders,  which 
He  with  their  long  axis  in  the  oblique  diameter  of  the  pelvis. 

Eighth  Step — External  rotation.  This  movement  of  the  head 
is  explained  by  the  movement  of  the  shoulders  within  the  birth - 
canal. 


Fig.  268. — Birth  of  the  shoulders.     Frozen  section  (Zweifel). 


Ninth  Step — Descent,  rotation,  and  birth  of  shoulders. 
The  anterior,  or  right,  shoulder  first  strikes  the  resistance  of 
the  pelvic    floor.      In    obedience    to   the   universal   law   already 

26 


402  THE   MECHANISM   OF  LABOR. 

enunciated,  that  whatever  portion  of  the  fetal  body  first  encoun- 
ters this  resistance  is  directed  downward,  forward,  and  inward, 
the  anterior  shoulder  is  compelled  to  travel  in  these  directions 
by  a  rotary  movement  of  the  shoulders  on  the  spine. 

The  anterior  shoulder  finally  appears  under  the  arch  of  the 
symphysis ;  unable  to  move  further  forward,  the  posterior 
shoulder  and  arm  are  propelled  over  the  floor  of  the  pelvis  and 
are  born,  their  escape  being  followed  by  the  birth  of  the  anterior 
shoulder  and  arm. 

Tenth  Step. — Delivery  of  remainder  of  the  body  by  a  move- 
ment so  rapid  that  the  eye  can  not  well  follow  it,  the  birth-canal 
being  so  widely  dilated  that  its  walls  offer  no  resistance  to  the 
escape  of  the  small  and  compressible  thorax,  abdomen,  and  lower 
extremities. 

ABNORMALITIES  IN  MECHANISM  AND  THEIR  MANAGEMENT. 

Abnormalities  of  Flexion  at  the  Inlet. — Imperfect  Vertical 
Flexion  in  a  Flat  Pelvis. — This  action  is  conservative  on  the  part 
of  nature,  and  has  the  effect  of  bringing  the  small  bitemporal  diam- 
eter (8  cm. — 314^  in.)  in  relation  with  the  contracted  conjugate. 
Associated  with  this  abnormality  are  found  anomalies  of  position 
and  lateral  flexion.  The  head  lies  transversely,  the  sagittal 
suture  running  in  the  transverse  diameter  of  the  pelvis,  and  the 
lateral  flexion  is  exaggerated  as  the  result  of  the  increased 
obliquity  of  the  pelvis,  the  increase  of  the  conjugatosymphyseal 
angle  and  the  posterior  parietal  bone  catching  on  the  promontory. 
The  exaggerated  lateral  inclination  of  the  head  is  accompanied 
by  overlapping  of  the  right  (anterior)  parietal  bone.  In  much 
exaggerated  lateral  flexion  the  anterior  parietal  bone,  or  even 
the  ear,  may  present.  In  exceptional  cases  (one-tenth)  the  pos- 
terior parietal  bone  may  present  in  consequence  of  the  anterior 
portion  of  the  head  catching  upon  the  pubic  spines.  These 
anomalies  of  mechanism  require  no  treatment,  as  a  rule.  They 
should  not,  indeed,  be  interfered  with,  as  only  by  these  means  is 
the  obstacle  of  a  contracted  pelvis  to  be  obviated  spontaneously. 
It  is,  however,  occasionally  necessary  to  interfere  on  account  of 
exaggerated  lateral  inclination.  A  presentation  of  one  ear  may 
demand  podalic  version.  A  less  exaggerated  lateral  inclination, 
especially  in  case  the  anterior  parietal  bone  catches  on  the  pubis^ 
is  ordinarily  easily  dealt  with  by  using  one  blade  of  the  forceps 
as  a  vectis  to  pry  down  the  retarded  half  of  the  head.  It  is  some- 
times possible  to  secure  spontaneous  engagement  by  exaggerating 
lateral  inclination;  for  this  purpose  one  blade  of  the  forceps  is  used 
to  pry  still  further  down  the  lower  half  of  the  head. 


ABNORMALITIES  IN  MECHANISM. 


403 


Anomalies  of  Direction. — In  anterior  displacements  of  the 
parturient  uterus  with  a  pendulous  belly  there  is  an  abnormal 
backward  direction  of  the  presenting  part,  or  a  direction  even 
upward  and  backward,  and  in  lateral  tilting  of  the  uterus  the 
presenting  part  is  propelled  against  the  opposite  wall  of  the  pelvic 
inlet  and  canal.  AH  progress  may  cease  as  the  head  butts  in  vain 
against  the  unyielding  bony  walls.  An  abdominal  binder  cor- 
rects the  anterior  displacements.  Placing  a  woman  on  the  side 
toward  which  the  fundus 
uteri  is  tilted  and  putting 
under  her  tlank  a  rolled 
blanket  or  pillow  corrects 
the  lateral  displacement. 

Anomalies  of  Rota= 
tion.  —  There  may  be 
abnormal  weakness  in 
resistance  or  propulsion, 
resulting  in  incomplete 
rotation.  Anomalies  of 
rotation  are  more  impor- 
tant in  cases  of  posterior 
positions  of  the  occiput. 

Anomalies  in  Vertical 
Flexion  at  the  Pelvic  Out= 
let. — Flexion  ma\'  be  in- 
complete if  the  head  does 
not  encounter  normal  re- 
sistance in  the  pelvic  cav- 
ity or  upon  the  pelvic 
floor,  or  it  may  be  exag- 
gerated, in  which  case  the 
vertex    impinges    on   the 

center  of  the   perineum   and   may   perforate   it.      Both   of  these 
anomalies  may  be  corrected  by  applying  the  forceps  and  lower- 
ing the  handles  for  incomplete,  raising   them  for  ovcrflexion,  as 
■  the  woman  lies  upon  her  back. 

Anomalies  of  Extension  and  Forward  Propulsion. — l-ailure 
of  extension  and  of  a  forward  propulsion  of  the  head  under  the  j)ubic 
arch  occurs  as  the  result  of  weakness  of  the  pelvic  floor,  in  conse- 
quence of  destruction  of  the  levatores  ani  muscles  in  a  formerlabor. 
Paradoxical,  therefore,  as  it  may  sound,  a  laceration  of  the  pelvic 
floor  in  one  labor  may  predispose  to  further  lacerations  in  the  next. 

Anomalies  of  Restitution. — This  movement  is  more  or  less 
theoretical  and  is  rarely  perfectly  performed.  It  fails  altogether 
if  the  neck  is  a  long  time  twisted  or  is  tightly  gnpped  b}'  the 
ring-  of  the  vulvar  orifice. 


269.  —  Pendulous  belly. 


404  THE   MECHANISM  OF  LABOR. 

Anomalies  of  external  rotation  are  due  to  an  imperfect  or 
anomalous  rotation  of  tlie  shoulders.  They  are  of  frequent 
occurrence. 

Anomalous  Descent  and  Rotation  of  Shoulders. — Rarely 
the  anterior  shoulder  is  caught  at  the  pelvic  brim  and  does  not 
descend.  The  posterior  shoulder  is  then  the  first  portion  of  this 
part  of  the  fetal  body  to  encounter  the  resistance  of  the  pelvic 
floor.  It  is  consequently  turned  forward,  inward,  and  downward, 
the  head  externally  following  this  movement  and  turning  un- 
expectedly with  the  face  to  the  left  and  the  occiput  to  the  rigJit, 
though  it  had  descended  the  birth-canal  and  escaped  from  the 
parturient  outlet  in  a  left  occipito-anterior  position. 

Mechanism  of  a  Right  Occipito=anterior  Position  of  a 
Vertex  Presentation. — Diagnosis. — Palpation  reveals  the  back  to 
the  right  anteriorly  ;  the  extremities  to  the  left  above  ;  the  head 
below.  The  heart-sounds  are  heard  near  the  median  line,  below 
the  umbilicus.  Digital  examination  shows  the  small  fontanel 
toward  the  right  acetabulum ;  the  sagittal  suture  in  the  left 
oblique  diameter  of  the  pelvis. 

The  mechanism  of  this  position  does  not  differ  from  the 
mechanism  of  the  L.  O.  A.,  except  in  that  the  occiput  being 
directed  toward  the  right  acetabulum,  the  rotation  of  the  head 
and  face  takes  the  opposite  direction, — that  is,  the  occiput  rotates 
anteriorly,  moving  from  right  to  left. 

The  Mechanism  of  Posterior  Positions  of  a  Vertex  Pres= 
entation,  R.  O.  P.  and  L.  O.  P. — Posterior  positions  of  the 
occiput  are  primary  or  acquired.  They  are  primary  if  the  head 
enters  the  inlet  with  the  occiput  posterior.  They  are  acquired  if 
the  head  rotates  from  an  anterior  position  at  the  beginning  of 
labor  to  a  posterior  position  at  its  close.  Acquired  posterior 
positions  of  the  occiput  are  very  rare. 

Diagnosis. — Palpation  reveals  the  fetal  back  in  the  maternal 
flank  (to  the  right  in  R.  O.  P.,  to  the  left  in  L.  O.  P.).  The  ex- 
tremities are  found  on  the  opposite  side  in  front,  the  head  below. 
The  heart-sounds  are  heard  in  the  flank  below  a  transverse  line 
through  the  umbilicus.  Digital  examination  shows  the  small 
fontanel  toward  the  right  or  left  sacro-iliac  joint ;  the  sagittal 
suture  in  an  oblique  diameter  of  the  pelvis. 

The  mechanism  is  the  same  as  the  mechanism  of  anterior 
positions,  including  anterior  rotation  of  the  occiput  under  the 
arch  of  the  symphysis.  As  a  consequence,  however,  of  the  pro- 
longed rotation  of  the  occiput,  sweeping  over  about  one-third  of  a 
circle,  a  peculiarity  in  the  mechanism  is  the  rotation  of  the 
shoulders  at  the  superior  strait  through  a  third  of  a  circle, — a 
movement  not  seen  in  anterior  positions.  And,  further,  in  con- 
sequence of  the  greater  distance  which  the  occiput  must  traverse, 


ABNORMALITIES   IN  MECHANISM.  405 

the  clinical  manifestations  of  this  position  are  different,  there  is 
greater  pain,  and  labor  is  more  prolonged.  After  rotation  has 
occurred  the  shoulders  descend  and  rotate  on  the  pelvac  floor,  as 
in  anterior  positions.  The  remainder  of  the  mechanism  is  identical 
with  that  of  anterior  positions. 

The  cause  of  the  forward  rotation  of  the  occiput  is  the  same 
as  it  is  in  anterior  positions, — namely,  ivJiatcvcr  portion  of  tlie 
fetal  body  first  strikes  the  resistance  of  the  pelvic  floor,  whether  it 
encounters  this  structure  behind  or  in  front  of  the  median  transverse 


Fig.  270. — Posterior  positions  of  a  vertex  presentation. 

line,  is  directed  forward,  inzvard,  and  downvuard,  binder  the  arch 
of  the  symphysis.  As  the  occiput  or  the  region  around  the  smaller 
fontanel  is  the  most  dependent  part  of  a  vertex  presentation,  it 
must  first  encounter  the  resistance  of  the  pelvic  floor,  and  must, 
accordingly,  be  rotated  in  the  directions  named. 

Abnormalities  in  Mechanism. — Backward  rotation  of  the  occi])ut 
complicates  labor  by  protracting  its  course,  increasing  the  danger  of 
fetal  death,  and  subjecting  the  mother  to  increased  risk  of  injury. 

The  causes  may  be  divided  under  three  heads  : 

Anomalies  of  Force. — Anterior  rotation  is  the  resultant  of  the 
forces  of  expulsion  and  resistance  ;  hence,  any  condition  disturbing 
the  normal  relation  of  these  forces  interferes  with  the  normal 
rotation.  Thus,  backward  rotation  occurs  if  there  is  dimin- 
ished expulsive  power,  increased  resistance  or  decrease  in  resist- 
ance, as  occurs  in  cases  of  very  large  pelves,  relaxed  jjclvic  floors, 
small  and  yielding  heads. 

Anomalies  oj  Flexion. — If  flexion  is  imperfect,  the  anterior 
vault  of  the  cranium  (as  in  those  rare  cases  of  j^rescntation  of 
the  large  fontanel),  the  brow,  or  the  chin  first  strikes  the  pelvic 


4o6 


THE   MECHANISM   OF  LABOR. 


-floor,  and  is,  therefore,  directed  forward,  and  the  occiput 'is  thus 
directed  backward. 


Fig.  271. — Posterior  position  of  a  vertex  presentation  :  backward  rotation  of  the  occiput. 

Insuperable,  Obstacles  to  Forivard  Rotation. — In  some  cases  if 
flexion  is  only  fairly  good,  and  the  occiput  docs  first  strike  the  pel- 
vic floor,  the  occiput  rotates  backward,  because  the  large  diam- 
eter of  the  head  (fronto-occipital,  1 1  ^  cm. — 4^  in.)  is  engaged, 


ABNORMALITIES  AV  MECHANISM.  407 

and  rotation  from  one  oblique  diameter  of  the  pelvis  to  the  other 
oblique  is  impossible,  on  account  of  the  very  tight  fit  of  the 
head  in  the  pelvis.  The  occiput  is  also  directed  backward 
for  the  same  reason,  if  the  fetal  head  is  oversized.  The  wedge 
of  a  prolapsed  extremity  may  prevent  forward  rotation.  In 
some  deformities  of  the  pelvis,  particularly  in  kyphotic,  generally 
contracted,  and  Naegele's  pelves,  the  occiput  rotates  backward. 
If  there  is  an  abnormal  projection  of  the  lumbar  and  sacral 
vertebrae,  interfering  with  rotation  of  the  shoulder,  the  head 
may  not  be  able  to  rotate  anteriorly.  Rarely  there  may  be 
rotation  of  the  head  without  a  corresponding  movement  of 
the  body,  and  the  result  is  an  exaggerated  torsion  of  the 
neck.  I  have  seen  a  child  fatally  injured  in  this  manner. 
In  the  other  cases  under  my  observation  and  in  most  of  the  re- 
ported cases,  however,  the  infant  has  escaped  unharmed. 

The  Mechanism  of  Labor  when  the  Occiput  Rotates  into  the  Hollow 
of  the  Sacrum. — The  occiput  is  propelled  forward  over  the  peri- 
neum by  increased  flexion  until  the  face  is  finally  born  under  the 
symphysis  by  partial  extension.  This  mechanism  subjects  the 
cranium  of  the  fetus  to  dangerous  pressure,  and  greatly  increases 
the  risk  of  perineal  rupture  by  subjecting  the  structures  of  the 
pelvic  floor  to  an  enormous  strain. 

Abnormalities  in  the  Mechanism  Just  Described. — There  may  be 
abnormal  resistance  to  the  descent  of  the  occiput,  resulting  in 
a  conversion  of  the  presentation  into  one  of  the  large  fontanel, 
brow,  or  face,  by  an  extension  of  the  head. 

As  causes  of  this  anomaly,  projecting  ischiatic  spines  or  a 
central  tear  of  the  perineum  have  been  reported. 

Treatment  of  Posterior  Positions  of  Vertex  Presentations. — 
The  medical  attendant  miist  bear  in  mind  the  causes  of  backward 
rotation,  and  should  try  to  prevent  its  occurrence.  For  this  pur- 
pose it  is  essential  to  secure  perfect  flexion  of  the  head  by  placing 
the  patient  on  that  side  toward  which  the  fetal  back  is  directed, 
and  to  obtain  a  normal  action  of  the  expulsive  and  resisting 
forces.  If  the  pelvic  floor  is  weakened,  and  does  not  supply 
sufficient  resistance,  it  should  be  reinforced  by  two  fingers  in  the 
vagina  or  by  a  single  blade  of  the  forceps,  imitating  the  shape 
and  direction  of  the  pelvic  floor,  and  used  as  a  lever  to  pry  the 
occiput  forward.  In  a  favorable  case  with  a  capacious  pelvis 
and  vagina  and  a  comparatively  small  head  it  is  possible  to  insert 
the  whole  hand  in  the  vagina  and,  gras])ing  the  head  with  tlic 
outstretched  fingers  and  thumb,  to  twist  tlie  occiput  forward.  It  is 
occasionally  possible  to  favor  rotation  of  the  head  by  an  external 
manipulation  of  the  shoulders.  Pusliing  that  shoulder  forward 
or  backward  which  is  most  easily  accessible,  the  anterior  rotation 
of   the   back   is   secured,    followed    ])erha])s    by   a   corresponding 


4o8 


THE   MECHANISM  OF  LABOR. 


rotation  of  the  head.  If  the  expulsive  power  is  fauUy,  a  single 
large  dose  of  quinin  may  be  administered,  or  forceps  may  be 
applied.  I  find  that  forceps  used  as  a  rotator  is  the  easiest  and 
surest  means  to  secure  forward  rotation  of  the  occiput  on  the  pel- 
vic floor.  As  traction  is  made  the  blades  gradually  turn  till  they 
are  three-quarters  of  the  way  upside  down.  They  are  then  removed 
and  reinserted  in  the  appropriate  manner  for  a  right  occipito-an- 
terior  position.  This  is  a  better  plan  than  the  rotation  of  the  head 
at  or  above  the  pelvic  brim.  As  in  the  vast  majority  of  cases  ro- 
tation occurs  spontaneously  on  the  pelvic  floor,  the  deep  insertion 
of  the  hand  and  the  rotation  of  the  head  at  the  brim  is  usually 
unnecessary.  If  backward  rotation  occurs  in  spite  of  the  precautions 
to  prevent  it,  extraordinary  care  should  be  exercised  to  protect 
the  vaginal  walls  and  the  perineum  from  laceration,  and  to  avoid 
a  protracted  second  stage  of  labor.  These  results  can  usually 
be  accompHshed  by  a  judicious  use  of  the  forceps.  It  might  be  an 
advantage,  in  rare  cases,  to  convert  the  vertex  into  a  face  presen- 
tation by  retarding  progress  of  the  occiput  and  assisting  the 
extension  of  the  head. 

Prognosis. — The    outlook    is    not    so    favorable    as   it   is   in 


Fig.  272. — Face  presentation  :  right  mento-anterior  and  right  mentoposterior  positions. 


anterior  positions  of  the  occiput.  The  forceps  is  often  required 
(once  in  seven  cases).  Laceration  of  the  maternal  soft  parts  is 
much  more  frequent.  The  mortality  of  the  tetus  is  increased 
from  less  than  5  per  cent,  (the  average  mortality  of  normal 
vertex)  to  more  than  9  per  cent. 

Fortunately,  backward  rotation  of  the  occiput  in  vertex  pres- 
entations occurs  in  only  about  i  yi  per  cent,  of  all  labor  cases. 


ABNORMALITIES  IN  MECHANISM. 


409 


Face  Presentations. — In  this  presentation  the  head  is  ex- 
tremely extended.  The  chin  is  the  most  dependent  and  prom- 
inent portion  of  the  presenting  part;  hence  the  positions  are 
named  by  its  relations  to  the  maternal  structures,  as  left  mento- 
anterior, right  mento-anterior,  etc.  Every  face  presentation  be- 
gins as  a  presentation  of  the  brow,  the  extreme  extension  only 
occurring  when  the  head  is  subjected  to  the  action  of  the  uterine 
pains  and  the  resistance  of  the  walls  of  the  genital  canal. 

Frequency. — Face  presentations  occur  about  once  in  250 
labors,  or  in  less  than  0.5  per  cent. 

Diagnosis. — The  unusually  prominent  bulk  of  the  cranial 
vault  is  felt  in  one  hypogastric  region  ;  a  deep  groove  between 
the  occiput  and  the  child's  back  may  often  be  made  out.  The 
fetal  heart-sounds  are  loudest  over  the  anterior  surface  of  the 
fetus,  or  on  that  side  of  the  maternal  abdomen  upon  which  the 
fetal  extremities  are  felt.  The  diagnosis,  however,  must  usually 
rest  on  a  digital  examination,  which  shows  before  the  onset  of 
labor  a  high  situation  of  the  presenting  part ;  a  flattening  of 
the  anterior  vaginal  vault ;  a  sharp  contrast  between  the  smooth 


Fig.  273. — Face  presentation.      l)cliviiy  ni  tiic  face. 

outline  of  the  fetal  forehead  and  the  irregular  cc^ntour  of  the 
face.  As  soon  as  the  os  is  dilated,  the  characteristic  features  of 
the  face  may  be  felt.  A  face  presentation  has  often  been  mis- 
taken for  a  presentation  of  the  brcccli.      Tlie  orbital   ridges,  the 


4IO  THE   MECHANISM  OF  LABOR. 

eye-sockets,  the  chin,  and,  most  distinctive  of  all,  the  hard 
gums  within  the  mouth,  should  enable  any  one  to  make  the 
differential  diagnosis.  This  presentation  should  be  considered 
as  a  pathological  one,  for  it  entails  great  danger  upon  both 
mother  and  child. 

The  causes  of  face  presentations  are  divided  under  three  heads, 
as  follows:  (i)  Conditipns  preventing  flexion,  as  tumors  of  the 
neck  ;  increased  size  of  the  thorax  ;  constriction  of  the  cervix 
about  the  neck  ;  coiling  of  the  cord  around  the  neck ;  tonic 
contraction  of  the  neck  muscles. 

(2)  Conditions  favoring  extension,  as  mobility  of  the  fetus  ; 
oblique  position  of  the  child  and  uterus,  especially  when  the 
abdominal  surface  of  the  child  is  directed  downward  and  the 
pejvis  is  flat ;  a  dolichocephalic  head,  in  which  the  posterior 
segment  of  the  skull  is  longer  than  the  anterior  ;  tumors  upon 
the  back,  as  spinal  meningocele.  Causes  which  promote  exten- 
sion of  the  trunk  and  shoulders,  and  consequently  of  the  head, 
as  an  overfilled  bladder  of  the  mother  pressing  upon  the  child's 
back.  After  the  head  has  descended  into  the  pelvic  cavity,  the 
face  presentation  may  be  due  to  the  conversion  of  an  occipito- 
posterior  position  into  that  of  the  face,  as  already  described. 

(3)  Anything  that  interferes  with  the  normal  engagement  of 
the  head  in  the  pelvis,  as  overgrowth  of  the  fetus,  deformed 
pelvis,  pelvic  tumor. 

The  Mechanism. — The  successive  steps  of  the  mechanism  of 
labor  in  a  face  presentation  occur  in  the  following  order  : 

Extension.  The  head  presents  at  the  superior  strait  imper- 
fectly extended,  so  that  every  case  of  face  presentation  may  be 
said  to  begin  as  a  brow  presentation.  There  is  also  at  first 
imperfect  engagement  of  the  presenting  part,  on  account  of  the 
large  diameters  presented  at  the  superior  strait.  Under  the 
influence  of  the  expulsive  action  of  the  uterus  and  the  resistance 
of  the  pelvic  walls,  the  brow,  caught  upon  the  pelvic  brim,  is 
held  stationary,  while  the  chin  descends  lower  and  lower  by  an 
extreme  extension  of  the  head. 

Molding,  or  an  accommodation  of  the  shape  of  the  presenting 
part  to  the  shape  of  pelvis,  occurs  to  a  moderate  degree  or  not 
at  all,  because  the  face  is  a  loose  fit  in  the  normal  pelvis.  The 
molding  is  confined  to  the  back  of  the  skull. 

Lateral  inclination  is  a  constant  feature,  so  that  one  cheek  is 
a  little  deeper  in  the  pelvic  canal  than  the  other  one. 

Descent  of  the  presenting  part  follows  the  dilatation  of  the 
cervical  canal,  the  descent  of  the  chin  being  accomplished  almost 
solely  by  the  extension  of  the  head,  and  not  by  a  descent  of  the 
head  as  a  whole. 

Anterior  rotation  of  the  chin  occurs  as  soon  as  it  encounters 


ABNORMALITIES  IN  MECHANISM. 


411 


Fig.  274. — Face  presentation,  chin  directed  laterally. 


Hg.  275. — Face  presentation,  chin  posterior. 


412 


THE   MECHANISM   OF  LABOR. 


the  resistance  of  the  pehdc  floor.  Anterior  rotation  is  followed 
by  the  engagement  of  the  chin  under  the  symphysis  pubis. 

Then  follows  the  delivery  of  the  head  by  flexion  and  propul- 
sion, the  mouth,  nose,  eyes,  and  forehead  sweeping  over  the  peri- 
neum and  appearing  successively  at  the  posterior  commissure. 

Restitution  and  external  rotation  follow  the  escape  of  the 
head  from  the  same  causes  that  impose  these  movements  upon 
the  head  in  a  vertex  presentation.  The  delivery  of  the  body 
takes  place  as  in  a  vertex  presentation. 

Abnormalities  in  Mechanism. — The  most  common  and  most 
important  anomaly  of  mechanism  is  a  delay  in  the  forward 
rotation  of  the  chin  under  the  symphysis.  This  delay  is 
due  to  the  difference  between  the  lateral  depth  of  the  pelvis 
(8.8  cm.,  or  3  ^  in.)  and  the  length  of  the  fetal  neck  (3.8  cm.,  or 
I  ^  in.),  as  a  consequence  of  which  the  chin  may  not  encounter 
the  necessary  resistance  to  turn  it  forward,  and  without  this  for- 
ward movement  it  is  impossible  for  the  head  to  escape  through 
the  vulvar  orifice.   Should  the  chin  be  directed  posteriorly,  where 


Fig.  276. — Face  presentation,  cliin  posterior;  eriflrmous  elongation  of  neck. 

the  depth  of  the  pelvis  is  even  greater  (5  inches),  the  delay  is 
absolute,  and  such  cases  can  only  be  terminated  by  artificial 
assistance.  If  the  condition  is  left  to  nature,  there  is  an  effort 
to  force  the  upper  portion  of  the  thorax  (9  cm.)  into  the  pelvic 
cavity,  along  with  the  posterior  half  of  the  child's  skull 
(9^  cm.),  for  only  thus  can  the  chin  descend  sufficiently  to  be 
turned  anteriorly  under  the  pubic  arch,  but  it  is  obviously  impos- 
sible for  the  bulk  of  these  two  diameters  to  pass  through  the  pelvis. 
If  the  chin  is  posterior,  it  may  rotate  to  a  transverse  position,  and 


Fig.  277. — Face  presentation. 


tf;^-  .     I. 


Fig.  278. — lace  preaciilatiuu. 


Fig.  279. — Face  presentation.  SpLLinnn  presented  to  the  author  by  the  late 
Dr.  Formad,  coroner's  physician.  i  lie  woman  had  died  during  futile  attempts  to 
extract  the  head  with  forceps.  The  chin  was  posterior,  but  had  rotated  to  a  lateral 
position,  without  corresponding  movement  of  the  shoulders.  This  brought  the  occi- 
put in  relation  with  the  right  shoulder,  so  preventing  any  further  extension  of  the 
head  and  adding  thereby  to  the  difliculties  of  the  case. 


414 


THE  MECHANISM  OF  LABOR. 


then  all  progress  may  cease,  because  the  occiput  catches  on  a 
shoulder  and  so  further  extension  of  the  head  is  prevented  (Figs. 
277,  278,  279).  A  most  serious  complication  of  face  presenta- 
tion for  the  child  is  the  displacement  of  the  arms  posteriorly  on 
the  child's  back  or  neck.^ 

Prognosis. — The  fetal  mortality  of  face  presentations  is   1 3  to 
15  per  cent.      The  maternal  mortality  rises  from  less  than  i  per 


Fig.   2S0. — Schatz's  method  of  cephalic  version. 

cent,  in  all  labors  to  6  per  cent,  or  over,  if  one  takes  into  account 
cases  .of  anterior  and  posterior   positions  and  those  which  are 

mismanaged  or    neglected  in 
general  practice. 

Treatment. — If  the  chin 
is  directed  well  forward  of 
the  transverse  diameter  of  the 
pelvis,  the  labor  may  require 
no  interference.  In  posterior 
positions  of  the  chin,  how- 
ever, the  case  is  always  diffi- 
cult, and  demands  active 
treatment.  Before  labor  be- 
gins, or  in  its  early  stages,  the 
face  presentation  may  be  con- 
verted into  one  of  the  vertex 
by  the  method  of  Schatz — 
external  manipulation  (see 
Fig.  280).  By  combined  pres- 
sure upon  the  breech  by  an 
assistant,  and  upon  the  an- 
terior wall  of  the  thorax  and 
the  occiput,  the  fetal  body 
is  flexed  and  flexion  of  the 
the  head  is  secured.    If  this  plan  fail,  the  methods  of  Baudelocque 

1  Lindenthal,  "  Centralbl.  f.  Gyn.,"  No.  25,  1899. 


Fig.  281 


The  conversion  of  a  face  into  a 
vertex  presentation  (Baudelocque). 


ABNORMALITIES  IN  MECHANISM. 


415 


(internal  and  external  manipulation)  should  be  tried  (see  Figs.  281, 
282,  283).  The  chin  is  pushed  up  by  the  internal  hand  while 
the  occiput  is  pressed  down  by  external  pressure,  or  the 
occiput   is    pulled   down   by   the  internal  hand,    while    external 


Fig.  282.  —  The  conversion  of  a  face  into  a  vertex  presentation  (Baudelocque) 


FiG.  2S3. — The  conversion  of  a  face  into  a  vertex  presentation  (Baudelocque). 
pressure    flexes    the    child's    body.       This     attempt    also    fail- 


4l6  THE   MECHANISM  OF  LABOR. 

ing,  version  should  be  tried  if  the  face  is  not  impacted  in 
the  pelvis.  While  labor  is  in  progress,  care  should  be  exercised 
not  to  rupture  the  membranes,  that  the  os  may  be  more  thor- 
oughly dilated  and  the  liquor  amnii  shall  not  be  drained  away. 
If  the  presenting  part  is  impacted  in  the  pelvis,  and  if  anterior 
rotation  of  the  chin  is  delayed,  it  may  be  hastened  by  two  fingers 
pressing  on  the  posterior  cheek  and  chin,  supplying  the  kind  and 
shape  of  resistance  that  should  be  afforded  by  the  pelvic  floor, 
which  the  chin  can  not  reach  ;  or,  if  more  convenient,  pressure 
may  be  applied  with  a  single  blade  of  the  forceps.  If  anterior 
rotation  can  not  be  effected  in  this  manner,  a  straight  forceps 
may  be  used  to  compel  rotation  by  twisting  the  head,  and,  if  the 
chin  is  directed  anteriorly,  traction  may  be  made  upon  the  for- 
ceps. If  the  chin  is  directed  backward,  traction  should  nevej' 
be  attempted.  Finally,  after  failure  of  efforts  to  convert  the  face 
presentation  into  a  presentation  of  the  vertex,  to  perform  version 
and  to  rotate  the  chin  craniotomy  is  necessary. 

At  the  last  part  of  the  second  stage  of  labor  care  must  be 
exercised  in  the  final  delivery  of  the  head,  not  to  push  the  neck 
too  forcibly  against  the  symphysis  while  trying  to  prevent  lacera- 
tion of  the  perineum. 

Presentation  of  the  Brow. — In  this  presentation  the  head 
remains  throughout  labor  midway  between  complete  extension 
and  complete  flexion.  Therefore,  the  largest  diameters  of  the 
head  present  at  the  superior  strait.  Of  all  presentations  of  the 
head  this  is  the  most  unfavorable  for  both  mother  and  child. 
The  four  positions  of  the  presentation  are  named  according  to  the 
direction  of  the  chin. 

Frequency. — In  Guy's  Hospital  there  were  14  brow  pres- 
entations among  24,582  births  (i  in  1756).  In  Bern  it  occurred 
44  times  in  19,725  labors^  (i  in  448). 

The  diagnosis  is  made  by  digital  examination.  It  would  be 
practically  impossible  to  distinguish  by  abdominal  palpation  the 
difference  between  a  face  and  a  brow  presentation. 

Mechanism. — The  steps  of  the  mechanism  are  the  same  as 
those  of  a  face  presentation.  If  the  chin  is  directed  posteriorly, 
progress  is  impossible,  for  the  same  reasons  that  make  a  poste- 
rior position  of  a  face  presentation  an  insuperable  obstacle  in  labor. 

Prognosis. — The  fetal  mortality  has  been  computed  to  be 
thirty  per  cent.  ;  the  maternal,  ten  per  cent.  The  latter,  however, 
depends  entirely  upon  the  woman's  treatment.  Competent  man- 
agement should  insure  the  mother's  safety. 

Treatment. — Before  labor,  or  in  its  early  stages,  the  brow 
should  be  converted  into  a  vertex  presentation.  This  can  some- 
times be  accomplished  by  external  pressure  on  the  occiput  to 
iRloosmann,  "  Inaug.  Diss.,  Bein,"  1903. 


ABNORMALITIES  IN  MECHANISM. 


417 


secure  flexion,  as  in  Schatz's  method  of  treating  a  face  pres- 
entation. If  this  plan  fail,  the  hand  may  be  inserted  into  the 
vagina  and  uterus  to  pull  the  occiput  down.  Should  this 
attempt  not  succeed,  it  would  be  best  to  convert  the  brow  into  a 
face  presentation  if  the  chin  is  anterior.  Failing  in  this,  version 
should  be  tried  if  the  waters  are  not  drained  off  or  if  the  present- 
ing part  is  not  fixed  in  the  superior  strait.  If  the  chin  is  anterior 
and  the  presenting  part  is  firmly  fixed  in  the  pelvis,  the  appli- 
cation of  the  forceps  usually  succeeds  ;  if  the  chin  is  posterior, 
and  if  conversion  into  a  vertex  presentation,  performance  of 
version  and  rotation  are  all  impossible,  craniotomy  is  indicated. 
In  face  and  brow  presentations  with  the  chin  posterior,  it  is  a 
cardinal  rule  not  to  use  forceps  except  as  rotators  ;  if  traction  is 
resorted  to  at  all,  even  in  mento-anterior  positions,  it  should  be 
employed  with  the  greatest  caution  and  gentleness.      Very  rarely 


i'ig.  284. — Presentation  of  the  greater  fontanel. 


the  head  may  be  brought,  down  far  enough  to  meet  with  resist- 
ance, and  thus  be  rotated  anteriorly  ;  but  unless  the  head  yields 
to  moderate  traction,  embryotomy  is  preferable. 

Presentation  of  the  Greater  Fontanel. — The  hc.id  in  this 
very  rare  presentation  is  set  squarely  upon  the  shoulders  in  a 
sort  of  military  attitude  of  attention,  turned  upside  down.  In 
its  clinical  features  this  presentation  resembles  that  of  a  brow. 
The  descent  of  the  head  is  difficult  and  tedious  ;  the  anterior 
(frontal)  portion  rotates  forward,  but  with  great  difficulty,  and 
serious  injury  to  the  maternal  soft  parts  is  almost  unavoid- 
able. The  stretching  of  the  vaginal  walls  is  so  great  that 
27 


4i8 


THE  MECHANISM  OF  LABOR. 


the  perineum  may  be  lacerated  into  the  rectum  before  the  head 
has  fairly  impinged  upon  the  pelvic  floor. 


Fig.  285. — Presentation  of  the  greater  fontanel ;  descent  of  the  head,  without  flexion, 

to  the  pelvic  floor. 

Treatment, — The  abnormal  position  of  the  head  should  be 
altered  into  a  vertex  presentation  by  pulling  down  the  occiput 
with  the  fingers  or  by  pushing  up  the  brow  while  pressure  is  made 
upon  the  occiput  from  above  through  the  abdominal  walls. 


ABNORMALITIES  IN  MECHANISM.  419 

Presentation  of  the  Breech. — By  a  presentation  of  the 
breech  is  meant  a  presentation  of  any  part  of  the  pelvic  extrem- 
ity of  the  fetal  ellipse.  The  term,  therefore,  includes  a  presenta- 
tion of  the  nates,  the  knees,  or  the  feet.  The  classification  of 
the  positions  is  made  by  the  direction  of  the  sacrum,  as  a  left 
sacro-anterior,  right  sacro-anterior,  etc. 

Frequency. — Breech  presentations  occur  in  1.3  per  cent,  to  3 
per  cent,  of  all  cases,  the  first  figures  referring  to  mature  births 
alone. 

Causes. — Abnormalities  in  the  shape  of  the  fetus  or  in  that 
of  the  uterine  cavity  are  the  chief  causes  of  a  breech  presenta- 
tion. Included  under  this  head  are  reversal  of  the  uterine  ovoid 
(the  lower  uterine  segment  larger  than  the  upper),  fetal  monstrosi- 
ties, twin  pregnancy.  Increased  mobility  of  the  fetus  accounts 
for  a  small  proportion  of  the  cases,  especially  in  premature 
births. 

Diagnosis By  abdominal  palpation  the  head  is  found  above, 

the  breech  below.  The  heart-sounds  are  heard  above  the  level 
of  the  umbilicus.  Digital  examination  shows  a  high  position  of 
the  presenting  part ;  an  absence  of  the  dome-like  projection  of 
the  vaginal  vault  which  is  found  in  a  presentation  of  the  head  ; 
the  bag  of  waters  projects  through  the  os  as  a  pouch-like  protru- 
sion ;  by  pressure  on  the  fundus  with  the  external  hand  the 
characteristic  features  of  the  breech  may  be  detected  by  the 
finger  in  the  vagina — namely,  the  nates  and  the  sulcus  between 
them,  the  tip  of  the  sacral  bone  and  the  coccyx,  the  thighs,  the 
external  genitalia,  and  the  anus.  Evacuation  of  meconium  is 
the  rule  in  a  breech  presentation  ;  so  that  the  examining  finger 
is  found  stained  with  it,  after  the  membranes  have  ruptured. 

Tlie  Mechanism  of  Labor. — The  following  steps  are  to  be 
noted  :  Dilatation  of  the  cervix  and  descent  of  the  breech  to 
the  pelvic  floor.  This  occurs  very  slowly,  because  the  soft 
breech  is  an  imperfect  dilator  of  the  cervix  and  an  ineffectual 
irritator  of  reflex  uterine  contractions  ;  hence  many  hours  may 
be  required  for  the  first  stage  of  labor.  Rotation  forward  of  the 
anterior  hip,  which  is  the  first  to  encounter  the  resistance  of  the 
pelvic  floor.  Owing,  however,  to  the  insufficient  resistance 
which  the  soft  breech  encounters,  its  rotation  is  imperfect. 

There  then  follows  the  birth  of  the  anterior  hip,  posterior  hip, 
the  thighs,  and  the  trunk.  Tlic  next  and  a  very  important  step 
is  the  engagement  and  descent  of  the  shoulders  in  an  oblique 
diameter  of  the  pelvis.  The  anterior  shoulder,  first  encountering 
the  resistance  of  the  pelvic  floor,  is  turned  forward  under  the 
pubic  arch.  Then  occurs  the  birth  of  the  anterior  followed  by 
that    of   the    posterior   shouklcr.      The    hcatl    h\    tliis    time    has 


420 


THE   MECHANISM  OF  LABOR. 


Fig.  286. — Breech  presentation,  right  sacroposterior  position. 


Fig.   287. — Breech  presentation,  left  sacro-anterior  position. 


ABNORMALITIES  IN  MECHANISM. 


421 


Fig.  288. — Breech  presentations,  left  sacro-anterior  position. 


Fig.  289.  —  Breech  presentations,  anterior  and  posterior  positions. 


422 


THE   MECHANISM  OF  LABOR. 


Fig.    290. — Same  as  figure  287,  showing  descent  of  breech  through  the  pelvic  canal. 


Fig.  291. — Same  as  figure  290,  showing  engagement  of  the  shoulders  in  the  pelvis. 


ABNORMALITIES  IN  MECHANISM. 


423 


Fig.  292. — Same  as  figure  291,  showing  escape  of  extremities. 


rig.  203. — Breech  presentation — rotation  of  the  hips. 


424 


THE   MECHANISM   OF  LABOR. 


entered  the  pelvis  with  its  long  diameters  in  the  oblique  diameter 
of  the  pelvis,  opposite  to  that  in  which  the  shoulders  engaged. 
The  head  descends  the  birth-canal  to  the  pelvic  floor  in  a 
position  of  extension.  The  occiput,  which  is  always  the  part 
first    to    strike    the    pelvic    floor,    is    rotated  forward   under  the 


■►^•'ifi  •' 


Fig.  294. — Breech  presentation.  V\'aldeyer"s  section  of  an  X-para  at  full  term, 
who  died  from  hemorrhage  some  hours  after  both  her  legs  had  been  cut  off  by  a  loco- 
motive :  a,  First  lumbar  vertebra;  Z^,  placenta  ;  r,  fractured  first  sacral  vertebra ;  d, 
coronary  vein;  <?,  blood  extravasation;  f,  pouch  of  Douglas;  g,  cervical  canal;  hy 
OS  externum  ;  i,  rectum  ;  j,  umbilicus ;  k,  os  internum  ;  /,  uterovesical  reflection  of 
peritoneum  ;  m,  bladder;   ;/,  symphysis  pubis  ;  <?,  vagina. 


pubic  arch.  There  follows  then  the  deliver}-  of  the  head  in  the 
following  order  :  Chin,  face,  forehead,  anterior  fontanel,  sweep- 
ing successively  over  the  perineum  and  appearing  in  the  vulvar 
orifice. 

Prognosis. — The   fetal    mortality   of   breech   presentations    is 
about  thirty  ^per  cent.,  including  badly  managed   cases  in   gen- 


ABNORMALITIES  IN  MECHANISM. 


4- 


eral  practice.  There  is  some  added  danger  of  injury  to  maternal 
soft  parts,  on  account  of  the  necessity  for  rapid  and  sometimes 
violent  extraction  of  the  after-coming  head. 

Treatment. — Before  labor  external  version  may  be  attempted. 
It  will  not  always  be  found  practicable,  and  after  the  fetal  body 
has  been  turned  there  is  a  disposition  on  the  part  of  the  fetus  to 
resume  its  original  position.  The  application  of  two  long  cylin- 
drical compresses  to  the  sides  of  the  uterus,  and  a  firm  abdomi- 
nal binder,  may  prevent  a  return  of  the  breech  presentation. 
When  labor  has  begun,  inaction  should  be  the  physician's  policy 
until  the  fetal  body  is  born  to  the  umbilicus,  unless  maternal  or 


Fig.  295. — Delivery  of  the  after-coming  head  when  it  is  flexed. 


fetal  life  is  threatened  or  an  indication  for  rapid  delivery  arises. 
As  soon  as  the  trunk  appears  the  patient  should  be  placed  in  the 
lithotomy  position  across  the  bed,  and  delivery  of  the  shoulders 
and  head  should  be  effected  by  pressing  upon  the  fundus  with  one 
hand,  the  other  hand  being  inserted  in  the  vagina  to  favor  anterior 
rotation  of  the  shoulder,  anterior  rotation  of  the  occij^ut.  and  to 
direct  the  passage  of  the  head  through  the  vagina  (W'icgand's 
method  ;   see  Delivery  of  the  After-coming  Mead). 

Abnormalities  in  Mechanism. — The  most  frequent  and   impor- 
tant anomalies  are  backward  rotation  of  the  occiput  and  excess- 


426 


THE  MECHANISM  OF  LABOR. 


ive  rotation  of  the  breech.  Backward  rotation  of  the  occiput 
is  very  exceptional.  The  mechanism  of  the  dehvery  of  the  head 
in  these  cases  differs  as  the  head  remains  flexed  or  becomes 
extended.  When  flexed,  the  chin,  face,  forehead,  and  anterior  fon- 
tanel slip  out  under  the  symphysis  in  the  order  named,  and  the 
head  is  delivered.  When  extended,  the  chin  catches  upon  the 
symphysis,  the  head  is  extremely  extended  and  is  born  by  the 
occipital  protuberance,  small  fontanel,  cranial  vault,  and  face 
slipping  over  the  perineum.  The  following  rules  for  managing 
the  extraction  of  the  head  in  these  cases  should  be  remembered  : 
If  the  head  is  flexed,  the  body  of  the  child  should  be  carried 
downward  ;  if  it  is  extended,  the  body  should  be  carried  upward 
over  the  mother's  abdomen.  Excessive  rotation  of  the  breech 
occurs  as  the  result  of  a  prolapse  of  a  posterior  extremity,  and 
is  of  no  great  practical  importance. 


Fig.  296. — Chin  arrested  at  symphysis  ;  head  extended  (Chailly-Honore). 


The  Mechanism  of  Shoulder  Presentations. — A  transverse 
position  of  the  child  in  utcro  almost  always  resolves  itself  into 
a  shoulder  presentation  as  the  result  of  uterine  contraction  when 
labor  begins.  Presentations  of  the  umbilicus  (Fig.  305)  and  of  the 
back  (Figs.  302,  303,  304)  are  possibilities,  but  are  extremely  rare. 
Shoulder  presentations  are  classified  according  to  the  positions 
of  the  back  and  head.  When  the  head  is  to  the  right,  the  back 
may  be  in  front  or  behind.  The  same  is  true  when  the  head  is 
to  the  left.  The  back  is  directed  anteriorly  twice  as  often  as 
posteriorly,  and  the  head  more  than  twice  as  often  is  found 
toward  the  left-hand  side  of  the  maternal  pelvis. 

Diagnosis. — Abdominal  palpation  reveals  the  fetus  in  a  trans- 
verse position.  The  heart-sounds  are  more  distinct  at  a  point 
corresponding  to  the  interscapular  region  of  the  child,  but  some- 
times can  not  be  heard.  A  digital  examination  shows  the 
characteristic  anatomical   peculiarities  of  the  shoulder  and  adja- 


ABNORMALITIES  IN  MECHANISM. 


427 


Fig.  297. — Shoulder  presentation. 


Fig.  298. — Shoulder  presentation. 


428 


THE   MECHANISM   OF  LABOR. 


Fig.  299. — Shoulder  presentation. 


Fig.  300. — Shoulder  presentation. 


ABNORMALITIES  IN  MECHANISM. 


429 


Fig.  301. — Transverse  position  of  the  fetus;  extremities  presenting. 


Fig.  302. — Back- presentation; 
the  left  arm  is  projecting.  The  trans- 
verse furrow  gives  the  appearance  of 
a  breech  presentation  (15udin). 


Fig.  303. — Back  presentation,  the 
two  arms  projecting  from  the  external 
genital  organs  (Budin). 


430 


THE   MECHANISM   OF  LABOR. 


Fig,  304. — Trunk  presentation,  dorsal  variety  (Budin 


Fig.  305. — Presentation  of  the  umbilicus 


ABNORMALITIES  IN  MECHANISM. 


431 


cent  parts — namely,  the  axilla,  the  clavicle,  the  spine  of  the 
scapula,  the  acromion  process,  the  head  of  the  humerus,  and  the 
ribs. 

Causes. — The  causes  of  a  shoulder  presentation  may  be 
divided  under  three  heads  :  (i)  Abnormalities  in  the  shape  and 
position  of  the  uterus,  as  a  pendulous  abdomen ;  a .  uterus 
bicornis ;  the  broad  uterus  accompanying  a  kyphotic  spine ; 
the  distorted  uterus  due  to  uterine  fibroids  and  other  abdominal 
tumors,  and  to  multiple  pregnancy.       (2)   Conditions  preventing 


Fig.  306. — Spontaneous  evolution. 


engagement  of  the  cephalic  or  the  pelvic  extremity  of  the  fetus, 
as  deformities  of  the  pelvis  ;  abnormally  large  child  ;  monstrosi- 
ties; placenta  praevia.  (3)  Abnormal  mobility  of  the  fetus,  as 
in  hydramnios,  after  fetal  death,  or  in  premature  births. 

Mechanism. — Strictly  speaking,  there  is  no  mechanism  of 
shoulder  presentations.  The  course  of  these  cases  is  impaction 
of  the  shoulder,  enormous  dilatation  of  the  lower  uterine  seg- 
ment, ascension  of  the  contraction-ring,  destruction  of  the  fetus  by 
prolonged  pressure,  and  death  of  tlic  mother  by  rupture  of  the 
uterus  or  by  exhaustion.      As  a  matter  of  fact,  however,  nature 


432 


THE   MECHANISM  OF  LABOR. 


can,   in  very  exceptional  cases,  effect  delivery  by  one  of  three 
methods  : 


Fig.  307. — Rare  form  of  mechanism, 
known  as  birth  with  doubled  body  (one- 
sixth  natural  size,  redrawn  from  Kiistner). 


Fig.  308. — Impending  rupture 
of  uterus  in  a  shoulder  presentation  : 
oe,  External  os  ;  oi,  internal  os ; 
C7-,  contraction-ring  (Schroeder). 


Fig.  309. — ^Frozen  section  of  shoulder  presentation.   If  the  mother  had  survived,  spon- 
taneous evolution  might  have  occurred  (Chiara). 


Spontaneous  version.      The  transverse  position  is  converted 
into  a  longitudinal  position  by  the  uterine  contractions. 

Spontaneous  evolution.     The  breech  slips  past  the  shoulder 


MECHANISM  OF   THE    THIRD   STAGE    OF  LABOR. 


433 


and  is  delivered  first,  the  rest  of  the  body  following  as  in  a 
breech  presentation. 

The  body  doubled  up  (corpore  reduplicato)  is  expelled  in 
one  mass.  This  termination  is  possible  only  in  premature  births 
with  a  small  child,  usually  macerated. 

Treatment. — The  treatment  of  shoulder  presentations  may 
be  summed  up  in  a  single  word — version.  If  the  child  is  dead ; 
if  the  shoulder  is  tightly  impacted  and  the  lower  uterine  segment 
is  so  distended  that  the  slight  additional  strain  upon  its  walls  of 
turning  the  child  will  probably  determine  a  rupture  of  the  uterus, 
the  child  should  be  decapitated. 

MECHANISM  OF  THE  THIRD  STAGE  OF  LABOR. 

The  mechanism  of  the  third  stage  of  labor  is  divided  into  two 
acts — the  separation  and  the  expulsion  of  the  placenta.  The 
most  probable  explanation  of  placental  separation  is  found  in  the 


Fig.  310. — Pinard  and  Varnier's  section  of  the  uterus  of  a  V-para  who  died 
from  collapse  (rupture  of  uterus  with  hemorrhage)  shortly  after  the  expulsion  of  the 
fetus  :  a,  Fundus  uteri ;  b,  membranes  still  attached  ;  < ,  retraction-ring  ;  </,  retroplacen- 
tal  blood-clot ;  e,  inverted  placenta ;  /,  contracted  os  e.xternum  ;  g,  cord  presenting. 


theory  of  a  diminution  in  the  area  of  tlic  i)hiccntal  site,  which  the 
placenta  follows  to  a  certain  point,  when,  becoming  solid  by  the 
approximation  of  the  villi  and  the  obliteration   of  the  lacuna;,  it 


28 


434 


THE   MECHANISM   OF  LABOR. 


can  no  longer  follow  the  contraction  and  retraction  of  the  uterus, 

and  is  sprung  off  from  the  uterine  wall.  It  requires  usually 
several  pains  to  accomplish  this  result ;  so  that  the  placenta  is 
not,  as  a  rule,  completely  detached  until  about  fifteen  minutes 
after  the  deliver}^  of  the  child,  when  it  may  be  found  lying  in 
the  dilated  pouch  of  the  lower  uterine  segment  and  cer\dcal 
canal.  The  walls  of  this  portion  of  the  birth-canal  are  so  flaccid 
from  pressure  paralysis  and    overdistention    that    the    placenta 


Fig.  311. — Crede's  method  of  expressing  the  placenta  (photographed  from  nature) 

(Dickinson). 

might  remain  there  many  hours,  perhaps  days,  unexpelled. 
Hence  it  is  that  artificial  assistance  is  almost  always  required 
to  express  the  placenta.  The  placenta  is  usually  expelled  like 
an  inverted  umbrella,  the  fetal  surface  coming  first  with  the 
membranes  trailing  after  it.  It  occasionally,  however,  escapes 
edgewise. 

Abnormalities  in  the  Mechanism  of  the  Third  Stage  of 
Labor. — Retention  of  the  placenta  occurs  very  frequently.  As 
the  placenta  is  fully  separated,  the  hemorrhage  is  slight.      The 


MECHANISM   OF   THE    THIRD   STAGE    OF  LABOR. 


435 


placenta  simply  lies  in  the  dilated  lower  uterine  segment  and  the 
upper  portion  of  the  vagina. 

The  treatment  is  the  proper  application  of  Crede's  method 
of   expression.       Sometimes    the    placenta    lies    across    the    os 


Fig.  312. — The  expulsion  of  the  placenta  edgewise  (Varnier). 

uteri  so  that  atmospheric  pressure  determines  its  retention.  In 
such  cases  a  finger  may  be  hooked  over  one  edge  to  pull  it 
down. 

Adhesion  of  the  placenta  to  the  uterine  wall  occurs  about  once 


Fig.  313 — The  expulsion  of  the  placenta  inverted  (N'arnier). 


in  312  cases.  The  adhesion  is  rarely  complete  ;  a  part  of  the 
placenta  is  usually  detached.  Hemorrhage  is  a  necessary  con- 
sequence.    The  placental  sinu.scs  arc  torn  when  the  placenta  is 


436 


THE   MECHANISM  OF  LABOR. 


detached,  but  the  womb  can  not  contract  and  close  them,  because 
of  the  attached  area  and  in  consequence  of  the  retention  of  the 
whole  placental  mass  within  the  uterus  (see  Fig.  314). 

Causes. — Adhesion  of  the  placenta  usually  occurs  in  a 
woman  who  has  had  endometritis  ;  often  as  a  consequence  of 
syphilis.      There  is  usually  an  excess  of  connective  tissue  in  the 


Fig.  314. — Partial  detachment  of  the  placenta^  Vertical  mesial  section  from  a 
case  of  eclampsia,  delivered  in  articitlo  mortis  by  forceps  :  a.  Placenta  still  attached  ; 
b,  placenta  separated  from  its  site  and  hanging  free ;  c,  membranes ;  d,  blood ; 
e,  membranes  (Stratz). 

decidua,  glandular  atrophy,  and  penetration  of  the  myometrium 
by  the  chorion  villi,  which  have  burrowed  into  it. 

Diagnosis. — Crede's  method  of  expression  fails  completely  to 
express  the  placenta ;  the  womb  will  not  firmly  contract,  and 
there  is  alarming  hemorrhage. 

Treatment. — The  hand  should  be  inserted  along  the  cord  as 


MECHANISM   OF   THE    THIRD    STAGE    OF  LABOR.        437 

a  guide  to  the  placenta.  K  detached  edge  should  be  sought, 
under  which  the  lingers  are  inserted,  and  the  separation  is  com- 
pleted with  the  finger-tips,  moving  them  from  side  to  side. 
Occasionally  it  is  necessary  to  pinch  through  a  dense  spot  of 
adhesion  with  the  thumb  and  forefinger.  The  placenta  being 
separated,  the  fingers  should  be  closed  about  it.  The  fundus 
should  be  stimulated  by  friction  through  the  abdominal  wall, 
and  the  uterine  contractions  should  be  allowed  to  expel  the  hand 


Fig.  315. — Method  of  manipulation  for  artificial   separation  of  the  adherent  placenta 

(Dickinson). 


and  the  contained  placenta.  It  is  unwise  to  pull  the  placenta 
out,  even  when  it  is  completely  detached,  for  the  combined  mass  of 
the  placenta  and  hand  may  act  like  the  piston  of  a  syringe  and 
draw  the  uterus  inside  out. 

Ahlfeld  has  reported  a  case  in  which  he  found  it  impossible 
to  detach  an  adherent  placenta.  He  packed  the  uterus  with 
gauze ;    on   removing   the    packing   twenty- four  hours  later  the 


438  THE   MECHANISM    OF  LABOR. 

placenta,  which  had  meanwhile  become  detached,  was  extracted 
clinging  to  the  last  strip  of  gauze/ 

Prognosis. — Many  women  die  from  hemorrhage;  about  seven 
per  cent,  from  sepsis.  Most  exceptionally  the  placenta  is  retained 
in  utero  for  months  without  doing  harm.^  The  rarest  anomalies  in 
the  mechanism  of  the  third  stage  of  labor  are  hernia  of  the  placenta 
through  the  muscular  coat  of  the  uterus  and  prolapse  of  the 
normally  situated  placenta.  The  latter  is  most  likely  to  happen 
with  twins,  after  rupture  of  the  uterus,  or  in  premature  labor,  but 
it  has  been  observed  at  term,  without  injury  to  the  uterus,  and  in 
a  single  pregnancy.  There  is  not  necessarily  profuse  hemorrhage 
nor  other  disadvantage  to  the  woman,  but  the  fetus  dies  unless 
it  is  extracted  at  once.^ 

1  '♦  Zeitschr.  f.  prakt.  Aerzte,"  Bd.  viii,  H.  13; 

2  Wallace,  "Indian  Medical  Record,"  abstract  in  London  ■'  Lancet,"  1891,  re- 
ports the  retention  in  iitero  of  an  almost  full  term  placenta  for  two  months  without 
inconvenience  to  the  mother.  Loisriel  ("Nouv.  Arch.  d'Obstet.,"  May,  1892,  sup- 
plem.)  reported  a  case  in  which  the  fetal  head,  after  decapitation,  was  left  in  the 
uterus  for  three  months  without  symptoms  of  sepsis.  Herrgott,  in  the  discussion  of 
this  report,  stated  that  he  had  seen  the  placenta  retained  within  the  uterus  for  seven 
months  after  childbirth. 

'  "  Prolapsus  Placenta;,"  Ingerslev,  "  Centralbl.  f.  Gyn.,"  No.  40,  p.  941,  1893  ; 
"  Zur  Kasuistik  des  Ptolapsus  Placentae  bei  normalem  Sitz  derselben,"  ibid..  No.  5, 
1893.  "  Hernia  of  the  placenta  through  the  muscular  coat  of  the  uterus  during 
labor,"  J.  G.  Lynds,  "Med.  News,"  1893,  p.  77, 


PART  IV. 
THE  PATHOLOGY  OF  LABOR. 


CHAPTER    I. 


ANOMALIES   IN   THE   FORCES   OF   LABOR. 

In  a  normal  labor  the  active  forces  of  expulsion  (the  uterine 
and  abdominal  muscles)  and  the  passive  forces  of  resistance  (the 
fetus,  the  pelvis,  and  the  maternal  soft  structures)  are  so  nicely 
balanced  that  the  expulsive  forces  are  just  sufficiently  resisted  to 
insure  a  slow  and  gradual  passage  of  the  fetus  along  the  birth- 
canal.  The  walls  of  the  birth-canal  and  the  structures  around 
the  vulvar  oriiice  are  by  this  arrangement  slowly  and  gradually 
dilated,  and  are  not  violently  torn  apart,  as  they  would  be  by  a 
more  rapid  expulsion  of  the  fetus.  This  balance  between  the 
powers  of  labor  is  easily  disturbed.  There  may  be  anomalies 
by  deficiency  and  anomalies  by  excess  in  the  component  parts 
of  the  forces  of  expulsion  and  in  all  the  sources  of  resistance. 
Thus,  the  uterine  muscle  may  be  too  weak  or  too  strong  com- 
pared with  the  resistance  it  must  overcome  ;  and  so  also  with 
the  action  of  the  abdominal  muscles.  The  resistance  furnished 
by  the  pelvis,  the  soft  structures,  and  the  fetus  may  be  excessiv^e 
or  deficient. 

Deficient  Power  of  the  Uterine  Muscle ;  Inertia  Uteri. — 
In  this  condition  the  uterine  muscle  is  unable  to  overcome  the 
normal  resistance  offered  by  the  weight  of  the  fetal  body,  by  the 
friction  of  the  pelvic  walls,  and  by  that  of  the  undilated  maternal 
soft  structures.  Inertia  uteri  is  manifested,  in  the  vast  majority 
of  cases,  during  the  first  stage  of  labor.  The  weakened  uterine 
force,  therefore,  is  almost  always  neutralized  by  the  obstruction 
of  an  undilated  cervix.  There  is  scarcely  another  condition  in 
obstetric  practice  that  can  be  traced  to  such  a  variety  of  causes 
or  that  demands  so  many  different  plans  of  treatment. 

Etiology. — Deficient  power  of  tlie   uterine   muscle   in    labor 

439 


44©  THE   PATHOLOGY  OF  LABOR. 

may  be  due  to  a  defect  of  the  muscle  itself,  to  some  anomaly  of 
innervation,  or  to  a  mechanical  interference  with  the  full  and 
effective  action  of  the  muscle.  Examples  of  the  first-named 
cause  may  be  found  in  imperfect  development  of  the  uterus  or  in 
anomalies  of  development,  as  in  uterus  bicornis.  The  uterine 
muscle  may  be  exhausted  by  rapidly  succeeding  pregnancies. 
It  may  be  overdistended  by  twins  or  by  hydramnios,  thus  losing 
the  power  gained  by  cohesion  of  muscular  bundles.  The  uterus 
may  be  weakened  by  some  cause — as  an  adynamic  fever  or  a 
wasting  disease — that  weakens  the  whole  organism,  but  it  does 
not  necessarily  follow  that  uterine  weakness  always  accompanies 
a  reduction  of  body-strength.  Women  in  the  last  stages  of 
phthisis  or  in  the  midst  of  an  attack  of  typhoid  fever  or  pneu- 
monia occasionally  exhibit  a  uterine  power  in  labor  above  the 
normal.  The  uterus  may  be  weakened  by  profuse  hemorrhage, 
as  in  placenta  praevia.  It  may  be  rendered  incapable  of  exerting 
normal  force  in  dry  labors.  The  liquor  amnii  having  drained  off 
completely  early  in  the  first  stage,  the  uterus  retracts  upon  the 
child's  body,  thus  being  subjected  in  certain  regions  to  severe 
and  long-continued  pressure,  and  becoming  in  those  spots  anemic 
and  friable,  while  in  the  areas  free  from  the  pressure  of  the  child's 
body  the  uterine  wall  becomes  congested,  swollen,  and  edematous. 
Above  all,  the  uterine  muscle  may  be  fatigued.  This  is  the 
commonest  cause  of  uterine  inertia.  It  is  seen  oftenest  in  primip- 
arae,  in  whom  inertia  is  more  than  twice  as  common  as  in  mul- 
tiparae,  on  account  of  the  difficulty  of  dilating  the  rigid  cervical 
tissues.  Inertia  may  appear  in  consequence  of  any  serious 
obstruction  in  labor.  At  first  the  pains  are  feeble,  infrequent, 
and  inefficient,  but  as  labor  continues  the  uterine  contractions 
gather  force.  The  inertia  from  this  cause  is  likely  to  be  only 
temporary,  seen  at  intervals  between  periods  of  stormy  uterine 
action  or  of  long-continued  tonic  spasms,  until  finally  ex- 
haustion of  the  whole  organism  threatens  the  patient's  life  or  the 
uterus  ruptures. 

It  has  been  asserted  that  an  anomaly  of  innervation  in  the 
anatomical  sense,  a  deficient  supply  of  the  terminal  nerves  in  the 
individual  muscle-cells,  is  a  cause  of  uterine  inertia,  but  it  is  not 
yet  clearly  demonstrated  to  be  so.  An  inhibitory  nervous  im- 
pulse to  the  uterine  muscle,  on  the  contrary,  is  a  frequent  cause 
of  uterine  inaction.  It  is  the  result  of  some  emotion  or  of 
great  pain.  That  the  "doctor  has  frightened  the  pains  away" 
on  his  first  arrival  has  become  proverbial  in  the  lying-in  room. 
The  presence  of  any  one  who  is  a  cause  of  embarrassment  or  is 
disagreeable  to  the  patient  may  have  the  same  effect.  In  hyper- 
esthetic  women  the  uterine   contractions  may  be  so  exquisitely 


ANOMALIES  IN   THE   FORCES    OF  LABOR.  44! 

painful  that  their  first  onset  is  followed  by  an  inhibitory  impulse 
which  cuts  them  short  almost  immediately.  Every  clinical 
observer  has  seen  the  phenomenon  of  rapidly  recurring,  very 
painful  uterine  contractions,  which  are,  however,  of  short  dura- 
tion, and  which  secure  no  appreciable  dilatation  of  the  cervical 
canal.  A  woman  may  be  tortured  thus  for  hours  in  the  early 
part  of  the  first  stage  of  labor,  when  this  inhibitor^'  nervous  im- 
pulse is  commonly  obsen,-ed.  With  the  continuance  of  labor  the 
individual  becomes  more  or  less  indifferent  to  her  surroundings 
or  more  inured  to  suffering,  and  the  inhibitory  nerves,  probably 
derived  from  the  spinal  cord,  apparently  lose  the  power  of 
responding  to  the  stimulus  of  pain. 

Among  the  mechanical  causes  of  inefficient  uterine  action 
during  labor  are  fibroid  tumors  of  the  uterine  walls,  displace- 
ments of  the  uterus,  old  peritoneal  adhesions,  and  fresh  out- 
breaks of  periuterine  inflammation. 

Diagnosis. — The  recognition  of  uterine  inertia  should  always 
be  easy.  The  contractions  of  the  muscle  are  of  short  duration 
and  are  separated  usually  by  long  intervals,  and  by  palpation  the 
observer  may  convince  himself  that  they  are  feeble.  The  uterus 
during  the  pain  does  not  assume  the  hard  consistency  which 
it  does  in  consequence  of  normal  vigorous  action.  The  patient's 
expression,  action,  and  demeanor  point  to  deficient  force  during 
the  pains.  The  woman  is  more  placid,  the  face  is  less  contorted, 
and  there  is  less  outcry  during  the  contractions  than  in  the  normal 
parturient  patient,  except  in  those  cases  in  which  excessive  pain 
inhibits  uterine  action.  In  these  cases,  however,  abdominal 
palpation  and  the  short  duration  of  the  pains  are  plain  signs  of  the 
inertia.  Finally,  labor  is  delayed.  During  the  first  stage  dila- 
tation is  slow  or  does  not  progress  at  all,  and  in  the  second  stage 
the  presenting  part  does  not  advance.  One  fatal  error  in  the 
diagnosis  of  inertia  uteri  should  be  avoided :  the  physician  should 
be  sure  that  labor  is  not  delayed  by  some  obstruction.  It  has 
happened  in  a  careless  and  superficial  examination  that  the  ob- 
sers'er  has  taken  the  distended  and  thinned  lower  uterine  segment 
for  an  inert  uterus.  In  such  a  case  the  measures  adopted  to  stimu- 
late the  supposedly  inactive  uterine  muscle  to  overcome  an  obstacle 
that  is  insuperable  might  easily  be  interrupted  by  rupture  of  the 
uterus.  A  methodical  and  careful  examination  avoids  this  error. 
The  source  of  obstruction  is  discovered.  The  firmly,  perhaps 
tetanically,  contracted  upper  uterine  segment  may  be  contrasted 
with  the  inactive  lower  segment  by  palpation  of  the  whole  anterior 
surface  of  the  uterus.  The  contraction-ring  should  be  visible, 
and  the  whole  uterus  stands  out  with  unusual  prominence,  from 


442  THE   PATHOLOGY  OF  LABOR. 

the  anteversion  that  always  accompanies  prolonged  and  powerful 
uterine  contraction. 

Treatment. — From  the  diversity  in  the  causes  of  inertia  uteri 
it  follows  that  no  single  plan  of  treatment  can  be  depended  upon. 
If  uterine  action  is  inhibited  by  emotion,  the  cause  of  nervous 
disturbance  should,  if  possible,  be  removed.  An  objectionable 
person  should  leave  the  room.  If  excessive  pain  prevents 
effective  contractions,  an  analgesic  should  be  administered. 
Nothing  is  better  for  this  purpose  than  chloral  administered  in 
15-grain  (0.97  gm.)  doses,  repeated,  if  necessary,  twice  at  inter- 
vals of  fifteen  minutes.  A  quarter  of  a  grain  (0.0162  gm.)  of 
morphin  hypodermatically  comes  next  in  order  of  efficiency.  If 
the  uterine  muscle  is  simply  apathetic,  it  can  be  aroused  by  some 
<^irect  irritant.  The  insertion  of  a  bougie  as  for  the  induction 
of  labor  answers  the  purpose  well.  A  more  effective  but  more 
troublesome  measure  is  the  dilatation  of  the  cervical  canal  by 
Voorhees'  bags,  which  not  only  irritate  the  uterine  muscle  and 
so  bring  on  strong  contractions,  but  also  artificially  dilate  the  cer- 
vical canal  and  thus  reheve  the  uterine  muscle  of  a  great  part  of 
its  task  in  the  first  stage  of  labor.  If  the  head  is  well  engaged 
in  the  pelvis,  however,  the  insertion  of  the  bag  is  difficult,  and  it 
is  likely  to  cause  malpositions.  In  such  cases,  if  the  os  is  dilated 
to  the  size  of  a  silver  dollar,  nothing  is  so  effective  as  the  appHca- 
tion  of  forceps — not  to  drag  the  head  through  the  undilated  cer- 
vical canal,  but  to  pull  it  at  intervals  firmly  down  upon  the  cervix. 
The  impact  of  the  head  upon  the  cervix  acts  as  a  powerful  reflex 
irritant,  and  excites  as  strong  contractions  as  any  direct  irritant  can 
do.  Not  only  so,  but  the  pull  of  the  head  upon  the  cervix  gradually 
dilates  the  canal  as  effectually  as  could  strong  propulsion  from 
above.  As  soon  as  effective  pains  are  established  and  the  dilata- 
tion of  the  cervical  canal  progresses  satisfactorily,  the  forceps 
should  be  removed. 

Inertia  uteri  so  profound  as  to  demand  the  somewhat  radical 
measures  just  described  is,  fortunately,  rare.  More  commonly 
the  physician  sees  the  minor  grades,  in  which  there  is  simply  a 
flagging  of  uterine  effort  during  the  first  stage,  especially  in 
primiparae,  accompanied  by  every  evidence  of  temporary  physical 
and  mental  exhaustion.  After  a  period  of  rest  effective  contrac- 
tions reappear,  even  if  nothing  whatever  is  done  to  aid  the 
patient.  The  more  complete  the  rest,  the  more  vigorous  is 
the  uterine  action  when  it  is  resumed,  and  for  this  reason  the 
administration  of  chloral  and  opium  is  often  followed,  after  a 
time,  by  a  satisfactory  progress  in  labor.  But  these  drugs  neces- 
sarily retard  the  termination  of  labor  by  the  time  of  rest  they 


ANOMALIES  IN   THE   EORCES    OF  LABOR.  443 

secure.  It  is  ordinarily  desirable,  therefore,  to  resort  to  drugs 
of  a  stimulant  character  that  shall  at  once  revive  the  flagging 
uterus  and  so  hasten  the  delivery.  Many  medicaments  have 
been  recommended  for  this  purpose,  but,  of  them  all,  alcohol, 
quinin,  and  ergot  alone  deserve  consideration.  The  last  was 
employed  extensively  at  one  time,  but  clinical  experience  forbids 
its  use  to-day.  The  contractions  of  the  uterus  induced  by  ergot 
are  likely  to  become  tetanic.  The  uninterrupted  contractions 
interfere  with  the  fetal  circulation  ;  they  may  cause  fatal  intra- 
uterine asphyxia,  and  they  often  produce  such  exaggerated 
blood-pressure  and  stagnation  of  the  current  in  the  fetal  body 
as  to  induce  extravasations  in  important  viscera,  especially  the 
brain.  Further,  the  circular  fibers  of  the  cervix  come  under  the 
influence  of  the  drug,  and  by  their  firm  contraction  neutralise 
the  contraction  of  the  longitudinal  fibers  of  the  uterine  body, 
and  thus  retard  labor  almost  indefinitely ;  and,  worst  of  all, 
should  there  be  some  obstruction  to  the  descent  of  the  child  in 
the  maternal  pelvis  or  in  the  fetal  body,  the  administration  of 
ergot  predisposes  to  rupture  of  the  uterus.  For  these  sufficient 
reasons  this  drug,  as  a  stimulant  to  the  uterine  muscle  in  the  first 
and  second  stages  of  labor,  should  be  banished  from  the  obstetri- 
cian's pharmacopeia,  except  in  the  single  instance  of  the  birth  of 
the  second  of  twins.  Owing  to  the  recommendations  of  Albert 
H.  Smith  and  of  Fordyce  Barker,  quinin  has  had,  and  still  has, 
a  great  reputation  as  a  stimulant  to  the  uterus  in  labor.  My 
experience  with  the  drug  does  not  permit  me  to  subscribe  unre- 
servedly to  its  efficacy  as  a  uterine  stimulant  in  labor.  Quinin 
has  the  positive  disadvantage,  moreover,  of  occasionally  producing, 
a  violent  postpartum  hemorrhage.  It  is,  however,  undeniable 
that  in  multiparae,  in  the  first  stage  of  labor,  15  grains  of  quinin 
often  proves  a  valuable  uterine  stimulant.  In  the  minor  grade  of 
inertia  under  description,  so  often  seen  in  primiparae,  and  almost 
always  the  result  of  exhaustion,  nothing  is  so  useful  as  alcohol, 
in  the  shape  of  a  wineglassful  of  sherr}-,  taken  slowh'  with  a  bis- 
cuit, and  given  with  the  positive  assurance  that  it  will  bring  back 
the  pains  and  hasten  the  conclusion  of  labor,  for  the  patient  often 
needs  moral  and  mental  support  as  much  as  she  requires  a 
physical  and  muscular  stimulus. 

An  impression  prevails  among  general  physicians  that  inertia 
uteri  in  the  first  stage  of  labor,  before  rupture  of  the  membranes, 
may  safely  be  disregarded.  In  a  measure  this  view  is  correct. 
There  is  often  a  partial  dilatation  of  the  os  and  then  an  entire 
cessation  of  uterine  contractions  for  many  hours  and  c\'en  for 
days.  I  have  seen  one  case  in  which  the  cervical  canal  was 
sufficiently  dilated  to  receive  four  fingers,  and  it  remained  so 
for  more  than  a  week,  the  patient  all  the  while  going  about  on 


444  THE   PATHOLOGY  OF  LABOR. 

her  feet  in  perfect  comfort,  without  a  single  painful  contraction 
of  the  uterus.  But  should  inefficient  uterine  contractions  be 
accompanied  by  much  pain,  as  happens  in  some  cases  of  inertia, 
the  long-continued  first  stage  should  not  be  regarded  with  indif- 
ference. The  patient  in  time  shows  the  irritant  and  depressant 
effects  of  long-continued  suffering  in  an  elevated  temperature, 
an  accelerated  pulse,  and  a  lessened  resisting  power  of  body-cells, 
the  last  playing  an  important  role  in  the  predisposition  to  sepsis 
after  labor.  Another  consequence  of  delayed,  painful  labor  may 
be  seen  in  sensitive,  nervous  individuals  who  are  at  first  thrown 
into  a  state  of  excitement  and  then  frorn  gloomy  forebodings  of 
harm  to  themselves  and  to  their  infants,  pass  into  an  almost 
maniacal  condition  of  terror  and  dread. 

It  should  be  a  rule  of  practice,  therefore,  to  watch  carefully 
all  cases  of  inertia  uteri,  and  to  interfere  as  soon  as  the  patient's 
mental  condition  or  her  pulse,  temperature,  and  general  vigor 
are  demonstrably  affected  by  the  delay  in  labor. 

Excessive  Power  in  the  Expulsive  Forces  of  Labor. — An 
actual  excess  of  power  in  the  expulsive  forces  in  labor  suffi- 
ciently great  to  expel  the  fetus  precipitately  is  extremely  rare. 
A  relative  excess  is  not  uncommon.  The  child's  body  may 
be  so  small,  the  pelvis  so  abnormally  large,  the  maternal  soft 
parts  so  relaxed,  that  the  ordinary  power  exerted  by  the  uterine 
and  abdominal  muscles  is  far  in  excess  of  that  required  to  over- 
come the  weak  resistance  offered,  and  the  child  is  fairly  shot  out 
of  the  birth-canal.  The  rapid  delivery  may  cause  serious  re- 
sults to  both  mother  and  child.  In  the  woman  the  structures 
of  the  pelvic  floor  may  be  lacerated  severely ;  the  sudden  evac- 
uation of  the  uterus  predisposes  to  hemorrhage  from  inertia ; 
the  placenta  may  be  detached  prematurely ;  and  the  sudden 
evacuation  of  the  abdominal  cavity  predisposes  to  dangerous 
syncope.  For  the  child  the  chief  danger  is  the  possibility 
of  unexpected  delivery  of  the  mother  in  the  erect  posture.  The 
umbilical  cord  may  rupture,  and  the  child,  falling  to  the  ground, 
may  be  fatally  injured.  Precipitate  and  unexpected  labors  occur 
most  frequently  when  women  are  seated  upon  the  water-closet. 
The  child  is  evacuated  into  the  waste-pipe  or  down  a  well  and 
may  be  destroyed.  Some  astonishing  examples  of  infantile 
vitality,  however,  are  furnished  by  such  cases. 

Unfortunately,  the  physician  is  usually  not  at  hand  to  pre- 
vent a  precipitate  delivery  and  to  avert  its  consequences.  Should 
he  find  an  infant  descending  the  birth-canal  with  a  rapidity 
dangerous  to  itself  and  to  its  mother,  he  can  easily  retard  its 
progress  by  pressure  with  his  hand  against  the  presenting 
part. 


ANOMALIES  IN   THE  FORCES   OF  LABOR.  445 

Excess  in  the  Resistant  Forces  in  Labor. — Deformities  of 
the  Pelvis. — A  comprehensive  and  satisfactory  knowledge  of 
deformities  in  the  female  pelvis  has  been  gained  only  in 
the  latter  half  of  the  nineteenth  century,  since  the  appearance 
of  Michaelis'  work  in  185 1.^  Until  the  announcement  by 
Arantius  in  the  last  quarter  of  the  sixteenth  century  that  a 
contracted  pelvis  is  a  serious  obstacle  in  labor,  the  prevailing 
belief  had  been  that  difficult  labors  from  mechanical  ob- 
struction by  the  maternal  bones  were  due  to  a  failure  on  the 
part  of  the  pelvis  to  expand  sufficiently  for  the  passage  of  the 
child.  This  idea  was  entertained  for  a  number  of  years  after 
Arantius'  time.  According  to  Litzmann,  Heinrich  von  Deventer 
(165 1  to  1724)  should  be  regarded  as  the  real  founder  of  our 
knowledge  of  the  pelvis  and  its  anomalies.  He  described  the 
inclination  of  the  pelvis,  the  axis  of  the  pelvic  inlet,  the  con- 
tracted pelvis,  and  the  flat  pelvis.  Pierre  Dionis  was  the  first 
to  point  out  (17 1 8)  the  relationship  between  rachitis  in  childhood 
and  a  deformed  pelvis  in  the  adult.  William  Smellie's  con- 
tributions to  the  study  of  the  female  pelvis  were  remarkably  full 
and  clear,  when  one  considers  how  little  was  known  before  his 
time.  His  description  of  the  rachitic  pelvis,  his  reflections  on 
its  cause,  and  his  accounts  of  illustrative  cases  may  be  read  with 
profit  to-day.  Roderer,  Stern,  Cooper,  Vaughan,  Denman, 
Baudelocque,  and  Fremerj^  added  much  to  the  stock  of  knowl- 
edge during  the  latter  half  of  the  eighteenth  century.  The  men 
to  whom  we  owe  most  of  our  present  information  about  the 
pelvis  and  pelvimetry  are  Naegele,  Kilian,  Rokitansky,  Michaelis, 
Robert,  Litzmann,  Neugebauer,  and  many  others  to  whom  refer- 
ence will  be  made  in  the  sections  devoted  to  tlie  particular  varie- 
ties of  deformed  pelvis.  ^ 

Frequency  of  Deformed  Pelves. — It  is  difficult  to  estimate  the 
frequency  in  America  of  pelves  sufficiently  deformed  to  influence 
decidedly  the  course  of  labor.  Statistics  from  our  lying-in 
hospitals  afford  little  aid  to  a  correct  conclusion,  because  the 
inmates  are  chiefly  European  immigrants  and  negresses.  In 
the  Boston  Lying-in  Hospital,  however,  deformed  pelves  were 
found  in  two  per  cent,  of  native-born  and  in  si.x  per  cent,  of 
foreign-born  women  (Reynolds).^  The  statistics  of  Williams  in 
Baltimore  and  of  Crossen  in  St.  Louis  give  a  frequency  of  about 
seven  per  cent,  among  the  white  women  of  large  American  cities. 
Among  negresses  deformities  of  the  pelvi.s  are  almost  three  times 

1  "  Das  enge  Becken." 

2  Litzmann,  "  Drei  Vortrage  iiber  die  Geschiclite  von  der  Lehre  der  Geburt  bei 
engem  Becken,"  in  his  "Geburt  bei  engeni  Becken,"  etc.,  1884. 

*  "Trans,  of  the  Amer.  Gyn.  .See,"  1890,  p.  367. 


446  THE   PATHOLOGY  OF  LABOR. 

as  frequent  as  in  white  women.  ^  My  experience  in  hospital  and 
consulting  practice  convinces  me  that  deformed  pelves  are 
by  no  means  rare  among  native-born  women  in  the  densely 
populated  centers  of  the  Eastern  States.  ^  No  general  practi- 
tioner, in  a  large  city  at  least,  can  hope  to  avoid  such  cases, 
and  it  is  likely  that  each  year  will  afford  him  one  or  more 
striking  examples.  It  follows  that  an  ability  to  recognize  deform- 
ities of  the  female  pelvis  is  a  necessary  accomplishment  for  every 
practitioner  of  medicine  who  may  be  called  upon  to  attend 
women  in  confinement,  and  that  a  knowledge  of  pelvimetry  is  as 
essential  to  the  intelligent  and  successful  practice  of  obstetrics 
as  are  percussion  and  auscultation  to  the  practice  of  medicine, 
European  statistics  bearing  on  the  frequency  of  contracted  pelves 
give  the  following  results  :  Michaelis  found  in  1000  parturient 
women  131  contracted  pelves  ;  Litzmann,  149,  Winckel  found 
in  Rostock  5  per  cent.,  in  Dresden  2.8  per  cent.,  and  in  Munich 
9. 5  per  cent,  of  contracted  pelves  among  pregnant  and  parturient 
women.  Winckel  believes  that  10  to  15  per  cent,  of  child- 
bearing  women  have  contracted  pelves,  but  that  in  only  5  per 
cent,  is  the  obstruction  serious  enough  to  be  noticed.  Kalten- 
bach  puts  the  frequency  of  contracted  pelvis  at  14  to  20  per 
cent.  In  Marburg  it  was  found  to  be  20.3  per  cent.,  in  Gottin- 
gen  22  per  cent.,  in  Prague  16  per  cent.  Schauta  estimates  it 
at  20  per  cent.  In  French  statistics  the  frequency  is  from  5  to 
16  per  cent.  ;  in  Austrian,  from  2  to  8  per  cent.  ;  in  Russian, 
from  I  to  5  per  cent. 

Classification  of  Anomalies  in  the  Female  Pelvis. — All  classifica- 
tions are  merely  a  convenience  for  the  teacher  and  student.  It 
is  rarely  possible  to  draw  sharply  defined  lines  between  varying 
manifestations  of  a  condition.  The  majority  of  German  authors 
follow  Litzmann's  classification  of  abnormalities  of  the  female 
pelvis,  by  which  they  are  broadly  divided  into  those  of  size  and 
those  of  shape.  Modern  French  authors  adopt  the  still  less 
satisfactory  division  of  oversize,  undersize,  and  anomalies  of 
inclination.  Schauta's  classification  is,  in  my  opinion,  the  most- 
convenient,  and  I  have  utilized  it,  with  a  slight  modification.^ 

^  J.  W.  Williams,  "  Obstetrics,"  vol.  i,  Nns.  5  and  6. 

2  In  the  Maternity,  the  i'hiladelphia,  the  University  Ho'^pitals,  and  in  the  South- 
eastern Dispensary  Service  there  have  been  over  15,000  births  during  my  connection 
with  these  institutions.  The  proportion  of  deformed  pelves  is  about  the  same  as  that 
found  by  Reynolds,  Crossen,  and  Williams  in  their  hospital  statistics,  so  that  I  have 
had  the  opportunity  of  observing  more  than  a  thousand  deformed  pelves,  including 
many  of  the  rarest  types.  In  my  own  private  patients,  however,  I  have  hardly  ever 
seen  a  deformed  pelvis,  and  I  imagine  they  are  extremely  rare  in  the  healthy  agricul- 
tural districts  of  America.  ^MijUer's  "  Handbuch." 


ANOMALIES  IN   THE   FORCES   OF  LABOR.  447 

ANOMALIES    OF    THE    PELVIS    THE    RESULT    OF    FAULTY 
DEVELOPMENT. 

Simple  flat  pelvis. 

Generally  equally  contracted  pelvis  ( justo-minor). 
Generally  contracted  flat  pelvis  (non-rachitic). 
Narrow  funnel-shaped,  fetal,  or  undeveloped  pelvis. 
Imperfect  development  of  one  sacral  ala  (Naegele  pelvis). 
Imperfect  development  of  both  sacral  ala;  (Robert  pelvis). 
Generally  equally  enlarged  pelvis  (justo-major). 
Split  pelvis. 
Assimilation  pelvis. 

ANOMALIES    DUE    TO    DISEASE    OF    THE    PELVIC    BONES. 

Rachitis. 

Osteomalacia. 

New  growths. 

Fractures. 

Atrophy,  caries,  and  necrosis. 

ANOMALIES    IN    THE    CONJUNCTIOTMS    OF    THE    PELVIC    BONES. 

Abnormally  firm  union  (synostosis),  which  is  found  in  elderly 
primiparae,  particularly  at  the  sacrococcygeal  joint  and 
in  the  joints  between  the  coccygeal  bones  : 
Synostosis  of  the  symphysis. 

"  "    one  or  both  sacro-iliac  synchondroses. 

"  "    the  sacrum  with  the  coccyx. 

Abnormally  loose  union  or  separation  of  the  joints  : 
Relaxation  and  rupture. 
Luxation  of  the  coccyx. 

ANOMALIES    DUE    TO    DISEASE    OF    THE    SUPERIMPOSED    SKELETON. 

Spondylolisthesis. 

Kyphosis. 

Scoliosis. 

Kyphoscoliosis. 

Lordosis. 

ANOMALIES    DUE    TO    DISEASE    OF    THE    SUBJACENT    SKELETON. 

Coxalgia. 

Luxation  of  one  femur. 

Luxation  of  both  femora. 

Unilateral  or  bilateral  club-foot. 

Absence  or  bowing  of  one  or  of  both  lower  extremities. 


448  THE   PATHOLOGY  OF  LABOR. 

Diagnosis  of  Pelvic  Anomalies;  Pelvimetry. — Deformities  of  the 
female  pelvis  may  be  detected  by  the  history  of  the  patient,  by 
her  appearance,  by  palpation  of  the  exterior  and  interior  of  the 
pelvis,  and  by  external  and  internal  measurements  of  the  pelvic 
diameters  that  are  accessible,  or  of  saUent  points  on  the 
woman's  body  corresponding  as  nearly  as  possible  with  the 
internal  measurements  desired,  the  relations  between  the  last 
two  having  been  ascertained  by  many  observations  on  dead  and 
living  bodies.  It  has  been  proposed  to  utiHze  the  Roentgen 
rays  in  the  diagnosis  of  pelvic  deformities,  but  this  method,  while 
it  shows  anomalies  of  form,  as  in  a  Naegele  pelvis,^  is  inferior 
to  digital  and  instrumental  pelvim.etry  in  determining  the  extent 
of  anomalies  in  size.-  For  taking  pelvic  measurements  the  ex- 
aminer's fingers,  a  tape-measure,  and  a  modified  mathematician's 
calipers — a  pelvimeter — are  usually  '  employed.  Baudelocque 
(1775)  was  the  first  to  devise  the  pelvimeter  in  ordinary  use.  He 
laid  the  foundations  of  pelvimetry;  his  instrument  and  methods 
are  in  use  at  the  present  time  (Figs.  316-320).  It  is  convenient 
to  describe  the  measurem.ents  of  the  diameters  of  the  pelvic  inlet, 
pelvic  cavity,  and  pelvic  outlet  separately. 

Measurement  of  the  Anteroposterior  Diameter  of  the  Superior 
Strait. — This  measurement,  the  most  important  in  the  pelvis, 
can  not  be  taken  directly.  It  must  be  estimated  by  several 
plans.  Baudelocque  was  the  first  to  point  out  the  relation  be- 
tween the  measurement  from  the  depression  under  the  last 
spinous  process  of  the  lumbar  vertebrae  to  the  upper  edge  of  the 
symphysis  pubis,  and  the  true  conjugate  diameter  of  the  pelvic 
inlet.  To  this  external  measurement  the  name  "external  conju- 
gate" was  given,  but  it  is  often  called  "the  diameter  of  Bau- 
delocque" (Fig.  320).  Its  discoverer  believed  the  relation 
between  the  external  and  internal  diameters  to  be  constant, — 
that  the  one  exceeded  the  other  by  8  to  8.75  centimeters, — but 
in  this  he  was  mistaken.  The  line  of  the  external  diameter 
does  not  usually  coincide  with  the  line  of  the  internal,  and  the 
thickness  of  bones  and  superimposed  structures  differs,  of  course, 
in  each  individual.  In  thirty  cases  in  which  Litzmann  had  an 
opportunity  to  compare  the  measurement  of  the  external  conju- 
gate taken  during  life  with  the  actual  measurement  of  the  true 
conjugate  taken  after  death,  there  was  an  average  difference  of 
9.5   centimeters,  but   the    maximum    difference  was    12.5   centi- 

^  Budin,  "  L'Obstetrique,"  1897,  p.  500. 

'^  See  Lewy  and  Thumin,  "Deutsche  med.  Wochenshr.,"  1S97,  No.  32;  also 
MuUerheim,  ibid..  No.  39.  Bouchacourt  and  Fabre  surround  the  pelvis  with  a  rec- 
tangular metal  frame  with  indentations  i  cin.  apart,  which,  reproduced  in  the  photo- 
graph, are  said  to  enable  one  to  estimate  the  size  of  the  pelves.  "  L'Obstetrique," 
1900,  p.  320;  Donnezan,  "These  de  Lyon,'"  1906. 


ANOMALIES  IN   THE   FORCES    OF  LABOR.  449 


Fig.  316. — Osiander's  pelvimeter. 


F'g-  317  • — Modern  combination 
of  Baudelocque's  and  Osiander's  pel- 
vimeter. 


Fig.  318. — Martin's  pelvimeter.         Fig.  319.— Harris-Dickinson  porlahle  jjelvimeter. 
29 


450 


THE   PATHOLOGY  OF  LABOR. 


meters  and  the  minimum  7  centimeters, — a  variation  of  5.5 
centimeters  in  a  small  number  of  cases.  Michaelis  found  a 
difference  of  0.6  to  3.2  centimeters  and  Schroeder  1.25  to  3 
centimeters  between  the  external  conjugate  of  the  living  body 
and  that  of  the  dried  specimen.  The  measurement  of  the  exter- 
nal conjugate,  therefore,  is  not  to  be  relied  upon  in  making  an 
estimate  of  the  size  of  the  true  conjugate.  It  simply  serves  to 
indicate  the  probability  or  the   improbability  of  pelvic  contrac- 


Fig.  320. — Measuring  the  external  conjugate  diameter  upon  the  Hving  female 

(Dickinson). 

tion.  An  external  conjugate  of  16  centimeters  or  under  means 
certainly  an  anteroposteriorly  contracted  pelvis ;  between  16 
and  19  centimeters  the  pelvic  inlet  is  contracted  in  more  than 
half  the  cases;  between  19  and  21.5  centimeters  there  are  but 
ten  per  cent,  of  contracted  pelves;  and  above  21.5  centi- 
meters it  is  almost  certain  that  the  conjugate  diameter  of  the 
pelvic   inlet   is  not   contracted   at   all.     The  external   conjugate 


ANOMALIES  IN   THE   FORCES   OF  LABOR.  45  I 

can  not  be  measured  accurately  without  some  practice.  The 
beginner  in  pelvimetry  will  do  well  to  remember  the  following 
rules  : 

Have  the  patient  dressed  for  bed.  Place  her  upon  her  side, 
with  the  thighs  slightly  flexed  and  the  clothing  rolled  well  up 
out  of  the  way,  the  lower  part  of  the  body  being  covered  with 


Fig.  321. — Kite-  or  lozenge-shaped  figure  on  ihe  back,  indicating  position  of  the 
depression  under  the  last  lumbar  vertebra  and  the  posterior  superior  spines  of  the 
ilia. 

a  sheet.  The  examiner  stands  at  the  patient's  back,  facing  her 
head.  The  depression  below  the  last  spinous  process  of  the 
lumbar  vertebrae  is  found  by  rubbing  a  finger-tip  over  the  lumbar 
spines  from  above  downward  until  the  finger  sinks  into  the  de- 
pression sought  and  feels  no  more  prominent  spinous  processes 


452 


THE   PATHOLOGY  OF  LABOR. 


below.  ^  Occasionally  this  point  is  perceptible,  a  lozenge-shaped 
figure  being  made  by  the  depression  under  the  last  lumbar 
vertebra,  the  posterior  superior  spines  of  the  ilium,  and  the  tip  of 
the  sacrum  (Fig.  321).  The  knob  at  the  end  of  one  branch  of  the 
pelvimeter  is  placed  firmly  in  the  depression  under  the  spinous 
process  of  the  last  lumbar  vertebra,  and  is  held  there  with  one 
hand,  while  the  fingers  of  the  other  hand  find  a  point  on  the 
symphysis  pubis  about  yi  of  an  inch  below  its  upper  edge, 
on  which  point  the  other  branch  of  the  pelvimeter  is  firmly 
set ;  the  pelvimeter  is  so  placed  that  the  indicator  is  turned  toward 
the  examiner;    the  measurement  is  therefore  easily  read  off  as 


Fig.  322. — Stein's  instrument  for  direct  measurement  of  the  conjugate. 

soon  as  the  pelvimeter  is  in  proper  position.     It  is  on  the  average, 
in  well-built  women,  2o|  centimeters. 

The  .  best  measurements  for  determining  the  length  of  the 
anteroposterior  diameter  of  the  pelvic  inlet  are  those  taken  from 
the  lower  edge  of  the  symphysis  pubis  to  the  promontory  of  the 
sacrum, — the  diagonal  conjugate  diameter,: — and  the  distance 
between  the  upper  outer  surface  of  the  symphysis  pubis  and  the 
promontory  of  the  sacrum.  The  diagonal  conjugate  diameter 
is  one  side  of  a  triangle,  the  other  two  sides  of  which  are  the 
height  of  the  symphysis  and  the  true  conjugate.  The  distance 
between  the  outer  upper  surface  of  the  symphysis  and  the  pro- 
montory of  the  sacrum  differs  from  the  true  conjugate  by  the 
thickness  of  the  upper  portion  of  the  symphysis.  Smellie  was 
accustomed  to  estimate  roughly  the  length  of  the  true  conjugate 
by  a  digital  examination,  basing  his  estimate  on  the  ease  with 
which  the  promontory  could  be  reached.  In  the  latter  part  of 
the   eighteenth   century  Johnson  ^   proposed,  for  estimating  the 

^  Michaelis  preferred  the  measurement  from  the  tip  of  the  last  lumbar  spinous 
process,  instead  of  from  the  depression  below  it. 

^Robert  Wallace  Johnson,  "A  New  System  of  Midwifery,"  etc.,  London, 
1769. 


ANOMALIES   IN   THE   FORCES   OF  LABOR. 


453 


size  of  the  pelvic  inlet,  a  method  which  consisted  of  inserting  the 
fingers  of  one  hand  in  the  mouth  of  the  womb  and  then  spreading 
them  between  the  promontory  and  the  sacrum.  A  few  years 
later  the  elder  Stein  devised  a  graduated  rod  for  measuring  the 
distance  between  the  lower  edge  of  the  symphysis  pubis  and  the 
division  between  the  second  and  third  sacral  vertebrse.  This  dis- 
tance he  believed  to  be  one-half  to  one  inch  greater  than  the  true 
conjugate.  Stein  later  constructed  the  instrument  for  the  direct 
measurement  of  the  conjugate  shown  in  figure  322.  Many  in- 
struments have  since  been  constructed  on  this  principle,  but  they 
are  impracticable  in  the  living  female,  for  obvious  reasons.  Baude- 
locque  was  the  first  to  propose  the  measurement  of  the  diagonal 
conjugate  and  the  subtraction  from  it  of  an  average  figure  (half 
an  inch)  to  determine  the  length  of  the  true  conjugate.  His 
method,  exactly  as  he  described  it,  is  still  in  use,  with  the  excep- 
tion that  two  fingers  instead  of  one  are  employed  in  measuring 
the  distance  between  the  symphysis  and  the  promontory.  To 
measure  the  diagonal  conjugate  correctly,  the  examiner  must 
have  the  skill  that  comes  of  practice,  and  he  must  conduct  his 


Fig.  323. — Measuring  the  diagonal  conjugate  diameter  (Dickinson). 


examination  in  a  careful  and  methodical  manner.  The  patient  is 
put  in  the  lithotomy  position  and  is  brought  to  the  edge  of  the 
table  or  bed  on  which  she  lies,  so  that  the  buttocks  project  well 
over  it.  The  examiner,  with  a  sterile  rubber  glove  ujjon  his  left 
hand,  anoints  the  first  two  fingers  with  an  unguent;  he  then  inserts 
these  fingers,  held  stiffly  extended,  inward  and  upward,  until  the 
tip  of  the  second  finger  finds  and  rests  upon  the  promontory  of  the 
sacrum.     Care  must  be  exercised  not  to  take  the  last  lumbar  for 


454 


THE   PATHOLOGY  OF  LABOR. 


the  first  sacral  vertebra  or  vice  versa,  nor  the  second  for  the  first 
sacral  vertebra — mistakes  easily  made  in  cases  of  so-called  "double 
promontory."  With  the  tip  of  the  second  finger  resting  firmly  in 
place  upon  the  middle  line  of  the  promontory,  the  radial  side  of  the 
hand  is  elevated  until  the  impress  of  the  arcuate  ligament  under  the 
lower  edge  of  the  symphysis  is  plainly  felt  upon  it.  With  a  finger- 
nail of  the  other  hand  a  mark  is  made  upon  this  point  of  the  ex- 
amining hand,  which  is  then  withdrawn  (Fig.  323).  The  distance 
between  this  mark  and  the  tip  of  the  middle  finger  held  extended 
is  taken  by  a  pelvimeter.  This  distance  is  the  diagonal  conjugate. 
By  the  observation  of  many  subjects,  alive  and  dead,  an  agreement 
has  been  reached  that  1.75  centimeters  should  be  subtracted  from 
the  diagonal  conjugate  to  obtain  the  true  conjugate  diameter. 

But  the  acceptance  of  this 
average  difference  depends 
upon  a  normal  height  of  the 
symphysis,  4  centimeters  ; 
a  normal  angle  between 
the  axis  of  the  pubis  and 
the  true  conjugate,  105°  ; 
a  normal  thickness  of  the 
symph\'sis,  and  a  normal 
height  of  the  promontory 
(Figs.  324  to  328).  These 
factors,  however,  are  not 
constant,  and  if  they  vary 
much  from  the  normal,  the 
most  skilful  and  most  ex- 
perienced obstetrician  may 
be  woefully  misled  in  his 
estimation  of  the  true  con- 
jugate. I  have  had  under 
my  care  a  rachitic  dwarf  in 
whom  there  was  more  than 
3  centimeters'  difference  between  the  diagonal  and  true  conju- 
gates, and  Pershing  found,  among  ninety  pelves  in  the  museums 
of  Philadelphia,  a  difference  vaiying  from  0.8  centimeters  to  3.6 
centimeters.  It  is  declared  that  these  sources  of  error  may  be 
eliminated  by  the  following  corrections  :  For  every  degree  of 
increase  in  the  conjugatosymphyseal  angle  add  half  the  number 
of  millimeters  to  the  sum  to  be  subtracted  from  the  diagonal 
conjugate,  and  vice  versa  ;  also,  for  every  0.5  centimeter  increase 
in  the  height  of  the  symphysis  over  the  normal  add  0.3  centi- 
meter to  the  sum  to  be  subtracted  from  the  diagonal  conjugate, 
and  vice  versa.  While  these  rules  are  admirable  for  the  study 
of  the  dried  specimen  in  a  museum,  they  are  not  easily  applied 


JIO 


Fig-  324. — Effect  of  different  inclinations 
of  the  pubis  upon  the  relationship  between 
the  true  and  the  diagonal  conjugate  diameter 
(Ribemont-Dessaignesj. 


ANOMALIES  IN  THE  FORCES   OF  LABOR. 


455 


to  the   living  pregnant   female.      The   height   of  the    symphysis 
can   be   measured   in   the   living   subject,   but  an  allowance   for 


Fig.  325. — Effect  of  different   thicknesses   of   the  symphysis  upon  the  relationship 
between  the  true  and  the  diagonal  conjugate  diameter  (Ribemont-Dessaignes). 


variations  in  this  respect  eliminates  error  in  only  a  small  propor- 
tion of  cases.  The 
variations  in  the  angle 
of  the  symphysis,  a 
much  more  important 
source  of  error,  can 
only  be  surmised.  In 
cases  upon  the  border- 
line between  the  re- 
lative and  absolute 
indications  for  Cesa- 
_  x.i-^         rean  section  in  which 

Syv\  \^ymf(m         ^^^^    difference    of    a 

\^^-^  -«k\^^^Mr  centimeter  would  de- 

cide one  for  or  against 
the  operation  I  prefer 
the  measurement 
between  the  upper 
outer  edge  of  the 
symphysis   pubis   and    the   promontory  of  the    sacrum    for  the 


Fig.  326.— Effect  of  different  heights  of  the 
promontory  upon  the  relationship  between  the  true 
and  the  diagonal  conjugate  diameter  (Ribemont- 
Dessaignes). 


456 


THE   PATHOLOGY   OF  LABOR. 


Fig.  327. — Effect  of  different  heights  of  the  symphysis  upon  the  relationship  between' 
the  true  and  the  diagonal  conjugate  diameter  (Ribemont-Dessaignes). 


Fig.  328. — Effect  of  the  lessened  slant  outward  of  the  symphysis  in  a  rachitic 
pelvis  upon  the  relationship  between  the  true  and  the  conjugate  diameter  (^Ribemont- 
Dessaignes). 


ANOMALIES  IN  THE  FORCES   OF  LABOR. 


457 


estimation  of  the  true  conjugate,  having  demonstrated  its  supe- 
rior  accuracy  in  practice.  For  taking  this  measurement  the 
patient  is  put  in  the  dorsal  posture,  with  the  buttocks  projecting 
beyond  the  edge  of  the  table  or  bed  on  which  she  lies.  A  mark 
with  the  point  of  a  lead-pencil  is  made  on  the  skin  over  the 
symphysis  pubis,  about  ^  of  an  inch  below  the  upper  edge. 
The  two  fingers  of  the  left  hand  are  inserted  in  the  vagina,  as 
in  measuring  the  diagonal  conjugate.  The  tip  of  the  middle 
finger,  having  found  the  middle  line  of  the  promontory,  is 
moved  a  little  to  the  patient's  right,  and  tip  b  of  the  pelvimeter, 
shown  in  figure  329,  is  made  to  take  its  place.  While  the 
examining  physician  holds  the  shaft  of  the  pelvimeter  firmly  in 


Fig.  329. — Author's  pelvimeter:  a,  For  measuring  the  true  conjugate  plus  the 
thickness  of  the  symphysis;  b,  with  extra  tip  added  for  measuring  the  thickness  of 
the  symphysis. 


place,  an  assistant  adjusts  tip  a  of  the  movable  bar  over  the 
mark  made  on  the  symphysis.  This  bar  is  then  screwed  tight, 
the  whole  pelvimeter  is  removed,  and  the  distance  between  the 
tips  is  found  by  a  tape-measure.  This  distance  is  the  con- 
jugate plus  the  thickness  of  the  symphysis  (Fig.  330).  The 
latter  I  have  found  to  be  i  centimeter  in  twenty-six  dried  pelves, 
i^  centimeters  in  nine,  i^  centimeters  in  thirteen,  i^  centi- 
meters in  four,  and  2  centimeters  in  three  specimens — one  a 
high-grade  rachitic  pelvis,  another  of  the  masculine  type,  and 
the  third  a  justomajor  pelvis.  The  thickness  of  the  symphysis 
is  measured  as  shown  in  figure  331.  In  living  subjects  the  index- 
finger  of  the  left  hand  must  find  the  inner  surface  of  the  symphy- 
sis  pubis,  and  must  follow  it  up  to  within  about  ^  of  an  inch 


458 


THE   PATHOLOGY   OF  LABOR. 


of  the  top,  where  it  bulges  to  its  full  thickness.  On  this  point 
one  tip  of  the  pelvimeter  is  placed,  and  it  is  then  held  in  position 
between  the  ends  of  the  first  and  second  fingers  ;  the  other  tip 
of  the  instrument  is  adjusted  over  the  mark  made  on  the  skin 


fig.  330- 


-Measuring  the  true  conjugate,  plus  the  thickness  of  the  symphysis,  with  the 
author's  pelvimeter. 


Fig.  331. — Measuring  the  thickness  of  the  symphysis,  with  the  author's  pelvimeter. 


externally ;  the  distance  is  read  off  from  the  indicator  provided 
for  the  purpose.  It  is  not  necessary  to  make  an  allowance  for 
the  thickness  of  the  tissues  over  the  symphysis,  for  this  is 
included  in  both  measurements,  and  on  subtracting  one  from 
the   other   the   necessary  correction   is  made.      The  tissues  over 


ANOMALIES  IN   THE   FORCES   OF  LABOR. 


459 


the  inner  surface  of  the  symphysis  can  usually  be  so  com- 
pressed by  the  knob  of  the  pelvimeter  as  to  be  practically  elimi- 
nated. If  this  is  impossible,  as  may  happen  in  some  primiparae, 
a  small  allowance  may  be  made  for  these  tissues — say,  at  the 
most,  0.5  centimeter.  In  measuring  a  pelvis  by  this  method  it 
may  be  necessary  to  anesthetize  the  patient ;  and  this  is  well 
worth  while  if  a  decision  between  some  of  the  more  serious  ob- 
stetrical operations  is  to  be  based,  as  it  must  be,  upon  an  accur- 
ate estimation  of  the  true  conjugate. ^ 

Farabeuf  has  invented  an  ingenious  pelvimeter  for  the  direct 
mensuration  of  the  true  conjugate  (Fig.  332).  Its  only  fault  is  the 
danger  of  traumatism  to  the  vesical  mucosa  from  the  intravesical 


Fig.  332. — Farabeuf 's  instrument  for  measuring  the  true  conjugate.     The  detachable 
retrosymphyseal  bar  is  inserted  in  the  bladder. 


bar,  which  must  be  firmly  pressed  against  the  inner  surface  of 
the  symphysis. 

v.  Bylicki  ^  has  devised  a  series  of  angulated  metal  rods  for 
the  direct  measurement  of  the  true  conjugate  (Fig.  333).  The 
author  has  no  experience  with  them. 

Neumann  and  Ehrenfest  have  devised  ingenious  instruments 
(Figs.  336  a-336  e)  for  directly  measuring  the  internal  pelvic 
diameters,  for  finding  the  inclination  of  the  pelvis,  and  for  graphi- 
cally recording  the  results  obtained.  The  author  has  tried  these 
instruments,  but  has  found  them  so  difficult  to  use  without  much 
practice  and  expert  assistance  that  they  are  only  practicable  in  a 
well-equipped  clinic  and  are  only  needed  in  rare  cases. 

1  Wellenbergh    was    the    first    to    employ    this    principle    in    pelvimetry.       His 
pelvimeter  was  improved  upon  by  van  Huevel,  and  in  recent  times  by  Skutsch  and 
by  Bullitt  ("Deutsche  med.  Wochen.,"  No.  13,  1890;  "Amer.  Jour.  Obstetrics," 
1893;  Muller's  "Handbuch  der  Geburtshiilfe,"  vol.  ii,  pp.  255,  260,  261). 
•    2  <«Monatshr.  f.  Geb.  u.  Gyn.,"  vol.  xx,  1904. 


460 


THE   PATHOLOGY  OF  LABOR. 


i\hlfeld,  Zweifel,  and  Jastrebow  have  also  devised  instruments 
for  exact  pelvic  measurements.^ 

Measurement  of  the  Transverse  Diameter  of  the  Stiperior 
Strait. — The  transverse  diameter  of  the  pelvic  inlet  can  not  be 
measured  directly,  nor  can  it  be  estimated  accurately.  Fortu- 
nately, it  is  not  necessary  to  do  it.  It  is  sufficient  to  deter- 
mine whether  there  is  a  decided  diminution  of  the  measurement, 
without  determining  the  exact  degree  of  lateral  contraction. 
To    do   this   the  following  measurements  are  relied  upon  :  The 


Fig.  2,2>3- — V.  Bylicki's  pelvimeter  for  measuring  the  conjugate  directly. 


'^,_:. 


Fig.  334. — Skutsch"  s  method  of  measuring  the  conjugate  diameter. 

distance  between  the  anterior  superior  spinous  processes  of 
the  iliac  bones,  which  in  well-formed  women  is  26  centimeters; 
the  distance  between  the  crests  of  the  iliac  bones,  29  centi- 
meters; the  distance  between  the  trochanters,  31  centimeters;  the 
distance  between  the  posterior  superior  spinous  processes  of  the 
iliac  bones,  9.8  centimeters;  the  distance  between  the  subpubic 

i-'Samml.  klin.  Vortrage   Gyn.,"  No.  l6i,  1906;  "  Zentralbl.  f.  Gyn.,"  Nos.  4 
and  27,  1906. 


ANOMALIES  IN   THE   FORCES   OF  LABOR. 


461 


ligament  and  the  upper  anterior  angle  of  the  great  sacrosciatic 
notch,  which,  according  to  Lohlein,  is  2  centimeters  less  than 
the  transverse  diameter  of  the  inlet;  finally,  an  estimation  of 
the  width  of  the  pelvic  inlet  by  a  vaginal  examination.  In  tak- 
ing the  external  measurements  the  woman  is  placed  upon  her 
back.  The  salient  points  are  easily  found  except  in  the  case 
of  the  iliac  crests.  They  are  discovered  by  moving  the  knobs 
of  the  pelvimeter  evenly  along  the  crests  of  the  ilia  until  the 
two  opposite  points  most  widely  separated  from  each  other  are 
found.  If  the  crests  are  no  further,  or  even  less,  separated 
from  each  other  than  the  spines,  points  five  centimeters  back  of 


Fig.   335. — Skutsch's  method  of  measuring  the  transverse  diameter  of  the  pelvic 

inlet. 


the  latter  are  arbitrarily  selected  as  the  sites  of  the  crests.  The  pos- 
terior superior  spinous  processes  are  often  marked  by  distinct  dim- 
ples on  the  woman's  back.  The  internal  measurement  of  Lohlein 
is  made  by  the  fingers  in  the  vagina.  If  all  tiiese  measurements  are 
much  less  than  normal,  a  lateral  contraction  of  the  pelvis  may 
be  assumed,  and  the  degree  of  contraction  is  roughly  estimated 
by  the  amount  of  decrease  in  the  measurements,  although  the 
relation  between  these  measurements  and  the  distance  sought  is 


462  THE   PATHOLOGY   OF  LABOR. 

very  variable.  The  efforts  of  Skutsch  and  of  others  before  him, 
accurately  to  measure  the  transverse  diameter  of  the  pelvic  inlet 
by  combined  internal  and  external  measurements,  have  not  yet 
been  crowned  by  success.  The  softness  of  the  tissues  externally 
permits  the  external  knob  of  the  pelvimeter  to  sink  into  the  flesh 
to  a  varying  degree,  and  the  same  is  true  of  the  structures  within 
the  pelvis.  It  is  difficult  also  to  keep  the  pelvimeter  in  the  same 
straight  line  when  the  internal  knob  is  changed  from  one  side  to 
the  other  (Figs.  334  and  335).  Moreover,  better  results  in  practice 
may  be  obtained  by  an  estimate  formed  by  a  vaginal  and  a  com- 
bined examination,  under  anesthesia  if  necessary,  of  the  relative 
size  of  the  transverse  diameter  of  the  pelvic  inlet  and  the  antero- 
posterior diameter  of  the  child's  head. 

Measurement  0}  the  oblique  diameters  of  the  pelvic  inlet  is  required 


Fig.  336. — Measurement  of  the  anteroposterior  diameter  of  the  pelvic  outlet. 

only  in  obliquely  contracted  pelves.  It  will  be  referred  to  in  the 
description  of  these  pelves. 

T/ie  Measurement  of  the  Capacity  of  the  Pelvic  Cavity. — The 
capacity  of  the  pelvic  cavity  must  be  estimated  by  vaginal  exami- 
nation. There  is  no  plan  by  which  accurate  measurements  can 
be  made.  It  is  sufficient  to  estimate  the  size  and  the  shape  of 
the  pelvic  canal  by  palpating  the  lateral  walls  of  the  pelvis;  by 
determining  the  curve,  perpendicularly  and  laterally,  of  the 
sacrum;  by  noting  the  height  of  the  sacrosciatic  notches,  the 
approximation  of  the  tuberosities  of  the  ischia,  the  depth  of  the 
pelvis,  and  the  direction  of  its  canal ;  by  detecting,  possibly,  the 
presence  of  an  exostosis,  an  osteosarcoma,  an  abnormally  project- 
ing spinous  process,  an  old  fracture,  or  asymmetry  of  the  pelvic 
walls  from  any  cause. 

Measurement  of  the  Transverse  Diameter  of  the  Pelvic  Outlet. 
— The  anteroposterior  diameter  of  the  inferior  strait  is  enlarged 


ANOMALIES  IN  THE   FORCES    OF  LABOR. 


463 


Figs.  336a-336f. — Neumann  and  Ehrenfest's  Pelvigraph  and  Kliseometer. 
i^Amer.  Jour.  Obstet.,  No.  ^,  igoj.) 


Fig.  336  a. 
Fig.  336  a. — The  pelvigraph  :  e.  Arm  for  the  promontory ;  a,  extrapelvic  por- 
tion;   /i,  marker;   c,  screw;    J,   spirit-level,   to  keep   successive  lines  on  the  pelvis 
horizontal. 


:*3-«». 


Fig.  336  b. — Detachable  arms 
for  the  pelvigraph  :  a,  For  the 
symphysis  ;  b,  for  the  promon- 
tory and  upper  sacrum ;  c,  for 
the  lower  sacrum  ;  d,  to  be  used 
in  case  of  a  rigid  perineum  ;  e, 
arm  for  measuring  the  transverse 
diameter  of  the  pelvic  inlet. 


Fig.  336  b. 


Fig.  336  c. — Measure- 
ments of  the  pelvis  in  suc- 
cessive horizontal  lines. 


464 


THE   PATHOLOGY  OF  LABOR. 


/ 


/ 


I 


\9 


Fig.  336  d. 

Fig.  336  d. — The  contour  and  dimensions  of  a  pelvis  anteroposteriorly,  plotted 
out  by  the  marker  (<5)  on  a  board  fastened  to  the  foot  of  the  examining  table. 


Fig.   336  e. 

Fig.  336  e. — The  kliseometer  for  determining  the  inclination  of  the  pelvis : 
a.  Rigid  arch,  between  the  patient's  thighs  in  the  erect  posture;  b,  anterior  knob; 
d,  posterior  Icnob  ;  c,  hollow  rod  ;  h,  indicator  ;  g,  spirit-level  ;  e,  rotary  disk.  By 
determining  the  inclination  of  the  inferior  strait  and  arranging  the  plotted  figure 
accordingly,  the  inclination  of  the  superior  strait  is  determined. 

The  principle  of  these  instruments  is  irreproachable.  They  are  indispensable 
in  the  accurate  scientific  study  of  an  unusual  case. 


ANOMALIES  IN   THE   EORCES   OF  LABOR.  465 

during  labor  by  the  displacement  backward  of  the  coccyx.  The 
transverse  diameter  between  the  tuberosities  of  the  ischiatic  bones 
is  constant,  and  if  there  is  contraction  of  the  outlet  the  greatest 
resistance  to  the  escape  of  the  fetus  is  furnished  by  these  firm 
bony  eminences.  The  transverse  diameter  of  the  pelvic  outlet 
can  be  measured  directly  with  ease.  The  woman  is  placed  in  the 
dorsal  posture,  with  thighs  and  legs  flexed.  The  distance 
between  the  tuberosities  of  the  ischia  is  measured  with  a  pel- 
vimeter, or  the  examining  physician  places  his  thumbs  squarely 
on  the  tuberosities,  and  an  assistant  measures  the  distance  be- 
tween the  physician's  thumb-nails. 

Williams  has  devised  a  con\'enient  pelvimeter  for  this  measure- 
ment with  rings  at  the  tips  to  accommodate  the  thumbs.  W.  R. 
Nicholson  has  devised  a  telescopic  rod  with  buttons  on  the  end 
and  a  graduated  scale,  which  is  the  best  instrument  for  the  purpose. 

If  it  should  be  desired  to  measure  the  anteroposterior  diameter 
0]  the  pelvic  outlet,  this  may  be  done  as  is  shown  in  Fig.  336, 
1.5  centimeters  being  subtracted  for  the  thickness  of  bone  and 
superimposed  structures,  or  the  extended  first  and  second  finger 
of  the  left  hand  may  measure  the  distance  from  the  lower  edge  of 
the  symphysis  pubis  to  the  tip  of  the  sacrum. 

It  is  customary  to  neglect  the  measurements  of  the  pelvic  outlet 
except  in  those  varieties  of  deform.ed  pelves  in  which  contraction 
of  the  transverse  diam.eter  may  be  expected,  as  in  the  funnel-shaped 
pelvis  and  in  kyphosis.  This  practice  may  be  said  to  be  justified 
by  clinical  experience.  In  considerably  more  than  a  thousand 
deformed  pelves  in  the  hospital  services  under  my  care  during 
twenty  years  I  have  seen  serious  obstruction  at  the  outlet  not 
more  than  five  or  six  times.  Williams,  of  Baltimore,  howe^■er, 
states  that  he  finds  a  contracted  outlet  in  8  per  cent,  of  the  women 
examined,  or  that  one  woman  in  twelve  has  a  decided  contraction 
(8  cm.  or  less)  of  the  transverse  diameter.  If  this  statement  should 
hold  good  for  other  localities,  contraction  of  the  outlet  may  be 
regarded  with  indifference  unless  it  is  much  below  8  cm.,  for  in 
the  vast  majority  of  cases  the  clinician  will  see  no  difficulty  in 
labor  from  it. 

Antepartum  Fetometry. — The  measurements  of  the  pelvis  are 
only  important  in  their  relationship  with  fetal  measurements. 
A  normal  pelvis  may  be  an  insuperable  obstruction  in  labor  if  the 
child  is  overgrown.  A  contracted  pelvis  may  be  no  obstacle  if  the 
child  is  small.  It  is  important,  therefore,  to  measure  or  estimate 
the  size  of  the  fetal  body,  especially  the  head,  before  labor  in 
estimating  the  difficulty  to  be  expected  and  in  selecting  the  proper 
treatment.  Several  methods  may  be  employed.  Miillefs  method: 
The  head  is  seized  between  the  fingers  of  the  outspread  hands 
30 


466  THE   PATHOLOGY  OF  LABOR. 

and  is  pressed  downward  into  and  if  possible  through  the  superior 
strait.  If  it  enters  readily  there  is  no  disproportion  between  the 
fetal  head  and  the  maternal  pelvis.  Perrefs  method:  With  a 
specially  devised  instrument  the  accessible  diameters  of  the  head 
are  measured  (the  occipitofrontal);  a  fold  of  the  abdominal  wall 
is  pushed  together  and  measured.  The  measurement  is  sub- 
tracted from  the  first.  Stone's  modification:  ^  The  occiptofrontal 
diameter  is  measured  through  the  abdominal  wall,  with  the  or- 
dinary pelvimeter;  no  deduction  is  made  for  the  thickness  of  the 
abdominal  wall;  2  cm.  is  subtracted  from  the  occipitofrontal 
to  find  the  biparietal  in  heads  with  an  occipitofrontal  diameter  of 
1 1  cm.  or  less,  or  5  cm.  is  subtracted  if  the  occipitofrontal  is  more 
than  II  cm. 

The  author  has  always  employed  and  prefers  the  followuig 
method:  As  the  head  lies  transversely  at  the  pelvic  brim,  it  is 
pressed  firmly  down  upon  the  brim  as  in  Miiller's  method;  the 
protrusion  of  the  anterior  parietal  eminence  beyond  the  upper  edge 
of  the  sym.physis  pubis  is  estimated  or  actually  measured  ;  the : 
true  conjugate  diameter  of  the  pelvis  is  estimated;  by  adding  the 
former  to  the  latter  measurement,  less  half  the  thickness  of  the 
symphysis,  the  biparietal  diameter  of  the  fetal  skull  is  found.  As 
a  matter  of  fact  mere  figures  in  the  measurement  of  the  head 
mean  little,  but  if  the  anterior  parietal  eminence  projects  i  cm. 
beyond  the  symphysis  with  the  fetal  head  lying  transversely  and 
pressed  firmly  down  upon  the  pelvic  inlet  spontaneous  engagement 
can  not  be  expected. 

Description  of  the  Several  Varieties  of  Abnormalities  in  the 
Female  Pelvis. — The  simple  flat  pelvis  (Fig.  337).  is  the  earliest 
recognized  form  of  contracted  pelvis — the  pelvis  plana  of  Deventer, 
who  did  not,  however,  make  a  distinction  between  the  simple  flat 
and  the  rachitic  flat  pelvis.  It  is  doubtful,  indeed,  if  he  knew 
the  difference  between  the  two..  Betschler  was  the  first  to  point 
out  the  distinctive  features  of  this  form  of  pelvis.  In  Europe  it 
is  the  commonest  variety  of  deformed  pelvis.  Schroder  states 
that  it  is  seen  more  frequently  than  all  the  other  forms  put 
together.  In  America  it  is  also  common,  but  the  equally 
generally  contracted  pelvis  is  encountered  here  as  often  or  per- 
haps oftener.  Out  of  a  series  of  3 16  pelves  in  women  of  Ameri- 
can birth,  I  have  found  eighteen  (a  percentage  of  5.6)  with  the 
measurements  characteristic  to  some  degree  of  a  simple  flat  pelvis. 

Characteristics. — In  the  simple  flat  pelvis  the  sacrum  is  small 
and  is  pressed  downward  and  forward  between  the  iliac  bones,  but 
is  not  rotated  forward  on  its  transverse  axis.      The  antero-pos- 

1  "  Medical  Record,"  Nov.  4,  1905. 


ANOMALIES  IN  THE   FORCES   OF  LABOR. 


467 


terior  diameter  is  contracted,  therefore,  throughout  the  whole  of 
the  pelvic  canal.  The  contraction,  however,  is  not  often  great.  It 
is  scarcely  ever  below  8  and  is  usually  not  under  9.5  centi- 
meters. 1 

The  transverse  diameter  is  as  great  as,  or  possibly  greater 
than,  that  of  the  normal  pelvis.  Occasionally,  however,  in  pelves 
approaching  the  type  of  the  generally  contracted  flat  pelvis  the 
transverse  diameter  may  be  found  somewhat  diminished.  There 
is  in  these  pelves  quite  frequently  a  double  promontory  formed 
by  the  abnormal  projection  of  the  cartilaginous  junction  between 
the  first  and  second  sacral  vertebrae.      The   line  drawn  between 


Fig-  337- 


-Simple  flat  pelvis:  C.  v.,  8^2  cm.;  tr.,  13^4  cm.;  obi.,  I2|^  cm.^  (model 
in  author's  collection,  University  of  Pennsylvania). 


the  lower  promontory,  or  the  second  sacral  vertebra,  and  the 
symphysis  is  often  as  small  as,  or  smaller  than,  the  true  con- 
jugate.^ 

Etiology. — The  simple  flat  pelvis  has  been  ascribed  to  heredity, 
to  an  arrested  rachitis,  to  overwork  before  puberty  (especially 
the  carrying  of  heavy  weights),  to  premature  attempts  to  walk 
or  to  sit  up,  and  to  the  weight  of  a  heavy  trunk  upon  a  pelvis 
ill  fitted  to  bear  it  on  account  of  weakness  of  its  ligaments.  It 
is  probable  that  in  the  majority  of  these  pelves  the  form  is 
inherited  and  congenital.  It  has  been  found  by  Fehling  in  a 
number  of  fetuses  and  new-born  infants. 

^  Engelken  has  described  a  specimen  with  a  true  conjugate  of  4.8  centimeters, 
a  diagonal  conjugate  of  7-5  centimeters,  with  transverse  and  oblique  diameters  of  the 
inlet  13.3  and  12.4  centimeters  respectively.      This  specimen  is  unique. 

*The  abbreviations  c.  v.,  tr.,  and  o/I.  will  be  used  throughout  to  designate  the 
true  conjugate,  the  transverse,  and  oblique  diameters  of  the  pelvic  inlet. 

•'  Crede  found,  in  nine  pelves  with  a  double  ])romontory,  the  conjugate  from  the 
true  promontory  longer  in  four  and  shorter  in  three  cases  than  the  conjugate  meas- 
ured from  the  false  promontory.  In  two  cases  the  two  conjugates  were  of  equal 
length  ("Klin.  Vortrage  iiljer  (Jeburtshiilfe,'    IJerlin,  1S53). 


468 


THE   PATHOLOGY   OF  LABOR. 


Diagnosis. — The  simple  flat  pelvis  is  easily  overlooked. 
There  is  nothing  in  the  patient's  appearance  or  history  to  sug- 
gest the  deformity,  unless  she  has  had  difficulty  in  previous 
labors.  The  characteristic  signs  are  the  diminished  anteropos- 
terior diameter,  determined  by  internal  and  external  measure- 
ments, and  a  transverse  diameter  as  great  as,  or  greater  than, 
normal,  or  perhaps  a  trifle  under  the  normal  measurement.  This 
last  point  is  determined  by  measurements  externally  and  by  the 
internal  palpation  of  the  pelvic  canal.  In  measuring  the  conju- 
gate diameter  of  the  flat  pelvis  one  must  take  into  account  the 
lessened  inclination  of  the  symphysis  outward,  its  height,  some- 


Fig.  338. — The  two  conjugates  of  a  double  promontory  :   From.,  True  promontory; 
F.  F.,  false  promontory  (Ribemont-Dessaignes). 


what  below  the  normal,  and  the  low  position  of  the  promon- 
tory. Usually  the  average  sum  of  i  ^  centimeters  is  a  sufficient 
amount  to  subtract  from  the  diagonal  conjugate.  If  there  is  a 
double  promontory,  as  is  frequently  the  case  in  this  form  of 
pelvis,  the  conjugate  must  be  measured  from  the  promontory 
nearest  to  the  symphysis,  usually  the  lower  (Fig.  338). 

Influence  upon  Labor. — From  the  failure  of  the  presenting 
part  to  enter  the  pelvis  during  the  last  weeks  of  gestation  there 
is  frequently  some  degree  of  pendulous  abdomen,  especially  in 
women  with  abdominal  walls  relaxed  from  previous  pregnancies. 
The  uterus  is  sometimes  broader  than   common,    and    is   often 


ANOMALIES  IN   THE   FORCES    OF  LABOR.  469 

tilted  to  one  side.  The  presenting  part,  if  the  head,  may  be  loose 
above  the  superior  strait,  resting  on  one  iliac  bone  or  on  the 
symphysis,  or  it  may  be  pressed  down  firmly  upon  the  brim  in  a 
transverse  position,  to  accommodate  its  longest  diameter  to  the 
longest  diameter  of  the  pelvic  inlet.  Malpresentations  are  com- 
mon, as  is  also  prolapse  of  the  cord  and  of  the  extremities.  The 
membranes  may  protrude  in  a  cylindrical  pouch  from  the  exter- 
nal OS  as  the  liquor  amnii  is  forced  out  of  the  uterus  without 
obstruction  from  the  imperfectly  engaged  head.  From  the  same 
cause  an  early  rupture  of  the  membranes  is  likely.  According 
to  Litzmann,  natural  forces  end  the  labor  in  79  per  cent,  of 
cases,  but  in  50  per  cent,  the  head  is  not  fully  engaged  until  the 
OS  is  completely  dilated. 

The  later  statistics  of  v.  Boennighausen  and  Kissinger  show 
a  spontaneous  termination  by  labor  in  a  much  smaller  proportion 
of  cases.  According  to  the  former,  36  per  cent,  in  pelves  with 
a  conjugate  above  8  cm.,  and  none  with  a  conjugate  below  8  cm.; 
according  to  the  latter,  85  and  17  per  cent,  respectively.  The  dila- 
tation of  the  OS  proceeds  slowly,  for  the  head  does  not  descend  low 
enough  to  press  upon  the  cervix.  Consequently  the  dilatation 
must  be  affected  by  a  retraction  of  the  cervix  over  the  head  or  by  the 
distended  membranes.  Should  the  latter  rupture,  the  os,  although 
considerably  dilated,  may  retract  until  the  head  at  length  descends 
and  again  dilates  it.  After  the  obstruction  at  the  superior  strait  is 
passed, — where,  of  course,  it  is  greatest, — the  head  usually  de- 
scends the  remainder  of  the  birth-canal  with  ease  and  rapidity, 
but  labor  may  be  prolonged  by  an  exhaustion  of  the  natural  forces 
in  the  attempt  to  secure  engagement.  The  apparent  anomalies  in 
the  mechanism  of  labor  characteristic  of  this  deformed  pelvis  are 
in  reality  the  best  possible  provision  for  the  spontaneous  obviation 
of  the  obstruction.  The  transverse  position  of  the  head  at  the 
inlet,  the  increased  lateral  inclination,  and  the  imperfect  flexion 
are  designed  to  accommodate  the  size  and  the  shape  of  the  head 
to  the  unnatural  size  and  shape  of  the  pelvic  inlet.  An  explana- 
tion of  these  peculiarities  in  the  engagement  of  the  head  may  be 
found  in  the  altered  relation  of  expulsive  and  resistant  forces. 
The  head,  forced  down  upon  the  flattened  brim  and  free  to  move 
upon  the  neck,  rotates  until  its  longest  diameter  is  adjusted  to 
the  greatest  diameter  of  the  inlet — the  transverse.  It  seeks  the 
direction  of  least  resistance,  as  any  inert  body  will  when  propelled 
through  a  contracted  canal.  But  the  transverse  position  of  the 
head  alone  is  not  sufficient  to  overcome  the  obstruction.  The 
biparietal  diameter  of  the  head  is  too  large  to  enter  the  conjugate 
of  the   pelvis.      The    occiput,  the  bulkiest  portion  of  the  skull, 


470  THE   PATHOLOGY   OF  LABOR. 

seeks  the  greater  space  to  one  side  of  the  promontory,  and  is 
pushed  against  the  lateral  brim  of  the  pelvis — the  iliopectineal 
line.  Here  it  is  arrested.  Further  propulsion  of  the  head  is 
secured  by  a  movement  of  partial  extension,  which  brings  the 
small  bitemporal  instead  of  the  larger  biparietal  diameter  of  the 
head  in  relation  with  the  contracted  conjugate.  Still,  the  obstruc- 
tion may  not  be  overcome.  Both  sides  of  the  head  may  be 
unable  to  enter  the  pelvis  at  once.  One  side  is  propelled  into 
the  pelvic  canal,  the  other  is  held  back.  That  side  which 
encounters  the  most  resistance  will  naturally  be  the  last  to  enter. 
Thus  it  is  that  usually  the  anterior  parietal  bone,  slipping  more 
easily  past  the  symphysis,  enters  first.  To  this  result  also  the 
inclination  of  the  pelvic  axis  to  the  axis  of  the  trunk  contributes. 
Owing  to  the  anterior  position  of  the  whole  sacrum  and  to  the 
diminished  anteroposterior  diameter  of  the  pelvic  outlet ;  on 
account,  also,  of  the  transverse  position  of  the  head  and  of  its 
imperfect  flexion,  rotation  of  the  head  on  the  floor  of  the  pelvis 
occurs  late,  and  occasionally  fails  altogether,  the  head  being 
expelled  from  the  vulva  in  its  original  transverse  or  in  an  oblique 
position. 

The  localized  pressure  to  which  the  maternal  structures  are 
subjected  results  sometimes  in  necrosis  of  cervical  tissue  over  the 
promontory  and  of  the  anterior  vaginal  wall  behind  the  sym- 
physis. On  the  child's  head  the  caput  succedaneum  is  not 
exaggerated,  because  the  head,  when  once  firmly  engaged  in  the 
pelvis,  descends  the  birth-canal  rapidly,  but  there  is  apt  to  be  a 
depression  on  that  portion  of  the  skull  applied  to  the  promontory 
— namely,  on  the  posterior  parietal  bone  between  the  greater 
fontanel  and  the  parietal  eminence,  usually  quite  close  to  the 
sagittal  suture  (Fig.  339).  Sometimes  a  succession  of  these 
depressions  or  a  gutter-shaped  groove  may  be  noted  in  a  line 
running  outward  and  forward  on  the  child's  skull.  More  fre- 
quently the  course  of  the  head  and  face  over  the  promontory  is 
marked  by  a  red  streak  running  from  the  depression  before  noted 
in  a  line  parallel  with  the  coronal  suture  toward  the  temple  if  the 
head  is  well  flexed  after  engagement,  or  to  the  outer  corner  of  the 
posterior  eye,  or,  in  case  of  extreme  flexion,  to  the  cheek  (Fig. 
340).  Usually  the  posterior  parietal  bone  is  depressed  below 
the  anterior,  which  overlaps  it  at  the  sagittal  suture.  The  pos- 
terior side  of  the  skull  is  also  flattened  from  the  greater  and 
more  prolonged  pressure  to  which  it  is  subjected.  Ordinarily 
the  lateral  inclination  of  the  child's  head  is  in  a  direction  from 
before  backward,  so  that  the  anterior  parietal  bone  presents  at  the 
center  of  the  superior  strait.      Occasionally  this  inclination  is  so 


ANOMALIES  IN   THE   FORCES    OF  LABOR.  47 1 


Fig.  339. — Depression  in  the  parietal  bone  caused  by  the  pressure  of  the 
promontory  (Winckel). 


Fig.  340.— Marks  made  by  the  promontory  on  the  child's  head  and  face 
(Fritsch  and   Kiistner). 


4/2  THE   PATHOLOGY  OF  LABOR. 

exaggerated  that  the  ear  is  the  presenting  part.  Exceptionally 
the  lateral  inclination  takes  the  opposite  direction,  the  anterior 
parietal  bone  catches  on  the  rim  of  the  pubic  bones,  and  the 
posterior  parietal  bone  is  the  iirst  portion  of  the  child's  head  to 
enter  the  pelvis.  The  presentation  of  the  posterior  parietal  bone 
occurs  even  in  normal  pelves  as  a  rare  exception,  but  is  seen  in 
about  ten  per  cent,  of  contracted  pelves  (Schauta),  and  is  the 
result  in  them  very  likely  of  firm  abdominal  walls  and  an 
increased  inclination  of  the  pelvic  inlet  to  the  axis  of  the  trunk. 
In  these  cases  the  anterior  parietal  bone  is  pushed  under  the 
posterior  at  the  sagittal  suture.  When  the  posterior  side  of  the 
head  by  descent  finds  room  in  the  hollow  of  the  sacrum  and 
moves  backward,  the  anterior  portion  of  the  skull  glides  over 
the  symphysis  and  the  sagittal  suture  moves  from  its  original 
position,  just  behind  the  symphysis,  toward  the  median  line  of 
the  pelvic  canal.  In  addition  to  these  anomalies  of  mechanism 
Breisky  describes  what  he  calls  an  "  extramedian  "  engagement 
of  the  head  in  cases  of  flat  pelvis  in  which  there  is  considerable 
lordosis  of  the  lumbar  vertebrae.  The  head  in  extreme  flexion 
is  forced  down  upon  half  of  the  pelvic  inlet,  and  enters  the  pelvic 
canal  on  this  side  alone.  Directly  the  obstructing  promontory 
and  lumbar  vertebra  are  passed  the  head  descends  the  pelvic 
canal  with  rapidity  and  ease.  This  mechanism  was  noted  nine- 
teen times  in  Breisky's  clinic  among  2002  labors.  1 

Justominor  Pelvis. — In  this  type  of  contracted  pelvis  the 
form  of  the  female  pelvis  is  preserved,  but  the  size  is  diminished. 
Three  divisions  of  this  pelvis  are  commonly  made  :  Th&  juvenile, 
in  which  the  bones  are  small  and  slender ;  the  inascidinc ,  in 
which  the  bones  are  large,  heavy,  and  thick  ;  and  the  divarf,  or 
pelvis  nana,  in  which  the  pelvis  is  very  diminutive  in  size  and 
the  pelvic  bones  are  not  joined  by  bony  union,  but  are  separated 
by  cartilage  as  in  the  infant.  The  innominate  bones  are  divided 
into  their  three  parts,  and  the  sacral  vertebrae  are  distinct  from 
one  another.  The  justominor  pelves  pass  by  insensible  grada- 
tions into  the  simple  flat,  the  transversely  contracted,  and  the 
generally  contracted  flat  pelves.  In  the  larger  cities  of  the 
United  States  the  justominor  pelvis  is  very  frequently  encoun- 
tered. It  is  certainly  as  common  here  as  is  the  simple  flat 
pelvis,  and  if  one  were  to  judge  from  hospital  patients,  among 
whom  there  is  a  large  proportion    of   shop-   and   factory  girls, 

^  "Die  Becken  Anomalien,"  by  Friedrich  Schauta,  in  Miiller's  "  Handbuch  dei 
Geburtshiilfe,"  Bd.  ii ;  Betschler,  "  Annalen  der  klinischen  Anstalten,"  i,  pp.  24,  60; 
ii,  p.  31  ;  Engelken,  "  Dis.-Inaug. ,"  Miinchen,  1878  ;  "  Zur  Kentniss  der  extra- 
median  Einstellung  des  Kopfes,"  Kohn,  "  Prager  Zeitschrift  f.  Heilkunde,"  Bd.  ix. 


ANOMALIES  IN   THE   FORCES    OF  LABOR.  473 

this  variety  of  contracted  pelvis  would  be  regarded  as  the  com- 
monest. 

Characteristics. — While  it  is  convenient  to  speak  of  the  justo- 
minor  pelvis  as  the  normal  female  pelvis  in  miniature,  the  de- 
scription is  not  strictly  accurate.  There  are  peculiarities  due  to 
an  arrest  of  development  which  give  to  the  equally  generally 
contracted  pelvis  some  of  the  features  of  an  infantile  pelvis. 
The  alae  of  the  sacrum  are  narrower  than  they  should  be  in 
comparison  with  the  bodies  of  the  vertebrae.  The  sacrum  is 
short  and  is  not  pushed  as  far  forward  between  the  iliac  bones 
as  it  usually  is  ;  it  shows  also  a  diminished  forward  inclination, 
and  on  its  anterior  surface  a  greater  lateral  and  a  less  marked 
perpendicular  concavity  than  common.  The  distance  between 
the  posterior  superior  spinous  processes  of  the  iliac  bones  is 
relatively  great,  on  account  of  the  posterior  position  of  the 
sacrum  and  its  slight  rotation  forward.  The  conjugatosym- 
physeal  angle  is  greater  than  normal,  by  reason  of  the  lessened 
inclination  outward  of  the  symphysis  and  the  pubic  bones.  The 
promontory  is  high  and  not  prominent,  and  the  inclination  of 
the  pelvic  entrance  to  the  abdominal  axis  as  the  individual  stands 
erect  makes  a  more  obtuse  angle  than  it  does  in  the  normal 
pelvis.  The  bones  in  this  form  of  contracted  pelvis  are  com- 
monly small  and  slender,  except  in  the  rare  masculine  pelvis, 
in  which  they  are  firm  and  thick  beyond  the  normal.  Women 
with  a  justominor  pelvis  are  ordinarily  of  slight  build  and  below 
the  medium  height ;  but  this  pelvis  may  be  found  in  individuals 
of  ordinary  stature,  and  sometimes  actually  in  tall  women  with  a 
large  frame. 

The  true  dwarf  pelvis  is  very  rare.  It  is  found  only  in 
women  of  dwarf  stature.  The  bones  are  slender  and  fragile, 
and  the  cartilaginous  junction  between  the  original  divisions  of 
the  pelvic  bones  is  preserved.  There  is  extreme  contraction  of  the 
pelvic  canal.  While,  strictly  speaking,  the  dwarf  pelvis  is  one  in 
which  there  is  an  arrest  of  development  and  a  failure  of  ossification 
m  the  junction  of  the  three  component  parts  of  the  innominate 
bones,  there  are  three  other  types  of  dwarf  pelvis  in  which  there 
is  extreme  contraction  of  all  the  pelvic  diameters:  the  cretin,  the 
achondroplastic,  and  the  hypoplastic.  The  distinctive  differences 
between  these,  types  may  interest  the  ])athologist,  but  are  of  no 
importance  to  the  obstetrician. 

In  the  commoner  kinds  of  justominor  })elvis  the  contraction 
is  not  often  very  great.  The  conjugate  diameter  is  seldom  below 
9  and  scarcely  ever  as  low  as  8  centimeters.  The  pelvic  outlet 
in  some  cases  is  laterally  contracted;  in  others  it  is  compar- 
atively roomy. 


474 


THE   PATHOLOGY  OF  LABOR. 


Etiology. — The  justominor  pelvis  is  the  result  of  arrested 
development ;  it  may  be  found  in  women  descended  from  a  stock 

that  has  deteriorated  phys- 
ically, or  in  women  sub- 
jected during  childhood, 
infancy,  or  intra-uterine 
existence  to  unfavorable 
hygienic  surroundings  or 
conditions. 

Diagnosis. — The  jus- 
tominor pelvis  is  easily 
confused  with  a  rachitic 
pelvis,  but  the  distinction 
is  readily  made  by  careful 
pelvimetry.  All  the  meas- 
urements, while  equally 
reduced,  bear  their  normal 
proportion  to  one  another, 
except  in  the  case  of  the 
external  conjugate  diam- 
eter, which  is  apt  to  be 
longer  than  would  be  ex- 
pected, on  account  of  the 
posterior  position  of  the 
sacrum  and  its  lessened 
inclination  forward.  In 
estimating  the  true  conjugate  diameter  from  the  diagonal  conju- 
gate one  must  often  take  account  of  the  increase  in  the  conju- 
gatosymphyseal  angle,  and  must  remember  that  the  sum  to  be 
subtracted  from  the  diagonal  conjugate  is  not  infrequently  greater 
than  common.  The  symphysis  is  less  in  height  than  in  the 
normal  pelvis,  but  the  error  of  computation  from  this  source  may 
be  disregarded.  Lohlein  lays  special  stress  upon  the  importance 
of  measuring  the  pelvic  circumference  in  making  the  diagnosis 
of  this  form  of  contracted  pelvis.  It  is  always  far  below  the 
normal,  ninety  centimeters.  An  internal  examination  of  the  pelvic 
cavity  and  inlet  should  be  made  carefully,  to  determine  approxi- 
mately their  capacity,  with  a  special  regard  to  the  approximate 
length  of  the  transverse  diameters. 

Influence  on  Labor. — The  mechanism  of  labor  shows  far 
fewer  anomalies  in  this  than  in  any  of  the  other  forms  of  con- 
tracted pelvis.  The  head,  from  the  greater  resistance  encoun- 
tered, is  strongly  flexed.  It  may  be  placed  transversely,  but  is 
quite  commonly  oblique,  and  may  even  be  anteroposterior  in 
position  if  there  is  a  tendency  to  lateral  contraction  of  the  pelvic 
canal.      By  the  perfect  flexion  of  the  head  the  obstruction  to  the 


Fig.  341.- 


-Dwarf  pelvis    (model    in    author's 
collection). 


ANOMALIES  IN   THE   FORCES    OF  LABOR. 


47  S 


Fig.  342. — Justominor  pelvis  witli  rup- 
tured pelvic  joints,  following  forceps  applica- 
tion :  C.  v.,  9^  cm.  ;  tr. ,  12^  cm.;  obi., 
II3^'  cm.  (author's  collection). 


progress  of  labor  is  in  great  part  obviated.  If  anything  inter- 
feres with  this  movement  of  the  head,  as  a  faulty  application  of 
the  forceps,  engagement  and  descent  may  become  impossible. 
Pelvic  presentations  in  labor  are  a  great  disadvantage  by  reason 
of  the  difficulty  experienced  in  freeing  the  arms  and  in  bringing 
the  head  last  through  the  generally  contracted  pelvic  canal. 
To  secure  its  rapid  passage, 
the  child's  head  must  be 
flexed  strongly  by  the  oper- 
ator's finger  in  its  mouth 
before  an  attempt  is  made 
to  secure  engagement  in 
the  superior  strait.  While 
the  woman  escapes  local- 
ized necroses  of  the  soft 
tissues  following  labor  in 
the  justominor  pelvis,  there 
is  greater  likelihood  of 
rupturing  pelvic  joints  in 
this  than  in  any  other 
variety  of  contracted  pel- 
vis, and  there  is  also  an 
extraordinary    liability    to 

eclampsia  (Fig.  342).  The  caput  succedaneum,  which  is  very  large 
on  account  of  the  early  fixation  of  the  head  and  the  long  labor,  is 
situated  directly  over  the  smaller  fontanel.  There  is  an  overlap- 
ping of  the  cranial  bones,  both  laterally  and  anteroposteriorly. 

The  generally  contracted,  flat,  non=rachitic  pelvis  presents  the 
combined  features  of  the  flat  and  the  generally  contracted  pelvis. 

Characteristics. — All  the  diameters  are  below  normal,  but 
the  conjugate  is  less  in  proportion  than  any  of  the  others.  This 
pelvis  has  many  of  the  features  of  a  rachitic  pelvis,  but  the 
anterior  half  of  the  pelvic  circumference  is  not  markedly  broad- 
ened ;  indeed,  it  is  often  the  reverse.  The  sacrum  is  small  and 
is  not  rotated  on  its  transverse  axis  ;  it  is  placed  further  back 
between  the  innominate  bones  than  in  the  normal  pelvis,  and 
very  much  further  back  than  in  the  rachitic  pelvis.  The  pro- 
montory is  high  and  is  not  prominent.  The  influence  of  this 
deformity  of  the  pelvis  upon  labor  is  that  of  a  flat  pelvis,  but  the 
difficulties  are  greater  than  in  the  case  of  the  simple  flat  pelvis, 
for  there  is  less  compensatory  room  in  a  transverse  direction. 
The  generally  contracted,  non-rachitic,  flat  pelvis  is  comparatively 
rare.  The  flattening,  according  to  Litzmann,  is  due  to  a  short- 
ening of  the  innominate  bones,  especially  at  the  iliopectineal 
line.  In  estimating  the  true  conjugate  diameter  of  the  generally 
contracted  flat  pelvis  it  is  safer  to  subtract  2  instead  of  i  3/^  cen- 


4/6  THE  PATHOLOGY  OF  LABOR. 

timeters  from  the  diagonal  conjugate,  on  account  of  an  increase 
in  the  conjugatosymphyseal  angle,  the  result  of  the  high  posi- 
tion of  the  promontory  and  the  diminished  slant  outward  of  the 
symphysis. 

Etiology. — The  generally  contracted  flat  pelvis  is  due  to 
hereditary  influence  or  to  an  arrest  of  development  in  the  embryo, 
fetus,  or  infant.  It  is  claimed,  however,  that  it  may  be  produced 
by  premature  attempts  to  walk  and  by  long  standing  upon  the 
feet  in  very  early  life. 

Diagnosis. — The  recognition  of  a  generally  contracted  flat 
pelvis  is  difficult.  The  measurements  usually  resemble  those  of 
a  generally  equally  contracted  pelvis,  but  the  conjugate  diameter 
is  less  than  one  expects  in  that  form  of  contracted  pelvis,  and 
the  mechanism  of  labor  is  that  of  a  flat  pelvis.  The  diagnosis 
can  be  made  by  finding  the  reduced  conjugate  diameter  and  by 
the  ease  with  which  one  can  reach  the  lateral  pelvic  wall  in  the 
palpation  of  the  interior  of  the  pelvic  canal.  A  certainty  of  diag- 
nosis can  be  obtained  during  life  only  by  the  direct  measurement 
not  only  of  the  conjugate  diameter,  but  also  of  the  transverse, 
by  the  methods  of  Lohlein  and  of  Skutsch. 

The  Narrow,  Funnel=shaped  Pelvis ;  Fetal  or  Undeveloped  Pelvis. 
— This  variety  of  pelvis  is  contracted  transversely  at  the  pelvic 
outlet,  or  both  in  the  transverse  and  anteroposterior  diameters, 
without  abnormalities  in  the  spinal  column  except  an  assimilation 
sacrum,  with  six  instead  of  five  vertebra.  The  depth  of  the  pelvic 
canal  is  much  increased  by  the  length  of  the  sacrum,  of  the  sym- 
physis, and  of  the  lateral  pelvic  walls.  The  sacrum  is  narrow, 
has  little  perpendicular  curve,  and  is  placed  far  back  between  the 
ilia  (Fig.  343).  Schauta  ascribes  this  form  of  contraction  to  an 
anomaly  of  development  by  which  the  pelvic  walls  are  lengthened 
downward  and  the  weight  of  the  body  is  thrown  backward  upon 
the  sacrum.  WilHams  believes-  that  in  three-fourths  of  the  cases 
it  is  due  to  a  high  assimilation  sacrum.  It  is  said  to  be  very  rare, 
but  it  has  been  found  quite  frequently  in  those  hospitals  where  the 
outlet  of  the  pelvis  is  regularly  measured.  It  comprises  from  5  to  9 
per  cent,  of  all  contracted  pelves,  according  to  Breisky,  and  Fleisch- 
mann  found  twenty-four  examples  in  2700  parturient  women.^ 
Williams  found  that  8  per  cent,  of  the  pregnant  women  examined 
(573  in  number)  had  this  form  of  pelvis.  A  slight  manifestation 
of  the  deformity  is  often  called  a  "m.asculine"  pelvis,  by  reason 
of  the  diminution  in  the  breadth  of  the  pubic  arch.  This  degree 
of  the  funnel-shaped  pelvis  is  frequently  encountered  (Fig.  344).  _ 

Diagnosis.— ll\\t  diagnosis  of  a  narrow,  funnel-shaped  pelvis 
is  made  by  a  comparison  of  the  measurements  of  the  pelvic  inlet 
with  those  of  the  outlet.     The  former  are  found  to  be  normal  or 

1  <'  Prager  Zeitschrift  f.  Heilkunde,"'  Bd.  ix,  H.  4  and  5. 


ANOMALIES  IN    THE   FORCES   OF  LABOR. 


A77 


even  greater  than  normal,  while  the  measurements  of  the  outlet  are 
diminished.    If,  as  is  the  rule  in  extreme  degrees  of  this  deformity, 
the  inlet  and  cavity  are  contracted,  the  outlet  is  still  smaller  in  pro- 
portion.    A  careful   palpa- 
tion of  the  pelvic  canal  is 
an  important  aid  to  a  cor- 
rect diagnosis.     The  pelvic 
walls  are  felt  to  converge 
as  they  approach  the  outlet ; 
the  narrowness  of  the  pubic 
arch  is  appreciated,  and  the 
approximation  of  the  tuber- 
osities and  spines  of  the  is- 
chiatic  bones  is  noticeable. 
Klein  ^   pointed  out  the 
necessity  of  measuring  wdiat 
he  calls  the  posterior  sagittal 
diameter    in    these    pelves. 
This  is  a  measurement  from 
a  line  drawn  between  the 

tuberosities  of  the  ischia  to  the  tip  of  the  sacrum, 
method  of  measurement  is  suggested  by  Williams, 
of  suitable  length  is  placed  between  the  tuberosities. 

measures   the 


Fig.  343. — Narrow,  funnel-shaped  pel- 
vis :  C.  v.,  loy^  cm.;  tr.  (inlet),  83^  cm.; 
tr.  (outlet),  7  cm.  ;  ant.  post,  outlet,  7^  cm. 
(specimen  in  the  author's  collection). 


Fig.  344. — Minor  grade  of  narrow,  funnel- 
shaped  pelvis  with  contracted  pubic  arch  (from 
a  plaster  cast  in  the  author's  collection). 


A  convenient 
A  lead  pencil 
A  pelvimeter 
distance  be- 
tween the  center  of  the  lead 
pencil  and  the  external  sur- 
face of  the  tip  of  the  sacrum. 
One  centimeter  deducted 
from  this  measurement  gives 
the  posterior  sagittal  diam- 
eter. WilHams  is  responsible 
for  the  statement  that  if 
there  is  lateral  contraction 
(not  specifying  how  much), 
and  if  the  posterior  sagittal 
diameter  is  below  8.5  cm., 
there  is  a  positi\'e  indication 
for  Cesarean  section  or  ]ju- 


biotomy.      This    statement 
must  be  confirmed  or  confuted  by  wider  experience. 

Influence  upon  Labor. — The  peculiarities  of  mechanism  in 
labor  are  malpositions  of  the  head  at  the  outlet  (as  backward  rota- 
tion of  the  occiput),  oblicjue  and  transverse  position  of  the  head, 
and  imperfect  flexion.  There  is  also  an  insufficiencv  of  the  ex])ul- 
sive  forces,  the  greater  part  of  the  fetal  Ijody  being  contained  in  the 

1  "  Volkmann's  Saminl.  kiln.  N'urtrage,"  1S96. 


478 


THE   PATHOLOGY  OF  LABOR. 


lower  uterine  segment,  cervix,  and  vagina,  while  the  upper  muscu- 
lar segment  of  the  uterus  is  in  great  part  emptied  and,  therefore, 
powerless.  By  the  approximation  of  the  pubic  rami  the  presenting 
part  is  forced  backward,  and  serious  lacerations  of  the  perineum  are 
to  be  feared.  The  pressure  of  the  head  upon  the  lower  birth- 
canal  may  result  in  necrosis  of  soft  structures  or  in  lacerations 
along  the  descending  rami  of  the  pubis  and  the  ascending  branches 
of  the  ischium.  The  tissues  over  the  projecting  spines  of  the 
ischia  are  also  the  seat  of  tears  or  of  necroses.  The  narrow- 
ing of  the  pubic  arch  may  lead  to  serious  injuries  if  forceps  is 
applied.  Lacerations  in  the  anterior  vaginal  walls  and  pro- 
fuse hemorrhage  may  follow  the  use  of  instruments.  In  well- 
marked  examples  of  the  narrow,  funnel-shaped  pelvis,  with  a  trans- 
verse diameter  at  the  outlet  not  much- below  7.5  cm.  (3  inches), 
pubiotomy  gives  the  best  chance  of  a  successful  termination  for 
mother  and  child.  Higher  grades  of  contraction,  with  a  diameter 
of  5  cm.  (2  inches)  and  under,  demand  Cesarean  section.  In  lesser 
grades  the  w^oman  may  be  delivered  spontaneously  or  by  forceps. 

Obliquely  Contracted  Pelvis  from  Imperfect  Development  of  the 
Ala  on  One  Side  of  the  Sacrum  {Naegele  Pelvis). — This  pelvis  was 
first  described  in    1834  by  Franz  Carl  Naegele,  ^  but  had  been 

noticed  as  early  as  1779 
without  a  full  understand- 
ing of  its  significance  (Fig. 

345)- 

Characteristics.  —  The 

pelvic  inlet  has  an  oval 
shape,  with  the  small  point 
of  the  oval  directed  to 
the  atrophied  side  of  the 
sacrum.  The  sacral  ala  is 
atrophied  or  is  absent  not 
only  in  that  portion  of  the 
bone  entering  the  sacro- 
iliac joint,  but  also  in  the 
transverse  process  along 
its  whole  length.  The 
sacro-iliac  joint  on  this  side  is  ankylosed  in  the  vast  majority  of 
cases,  but  not  invariably.  The  sacrum  is  narrow,  asymmetrical, 
and  turned  with  its  anterior  face  toward  the  deformed  side  of  the 
pelvis.  The  promontory  is  not  only  turned  in  this  direction,  but  is 
also  pulled  over  to  the  diseased  side.    The  innominate  bone  on  the 

1  "Die  Heidelbeiger  klinischen  Annalen,"  Bd.  x,  p.  449.  More  elaborately 
described  in  his  folio  atlas,  "  Das  Schrag  verengte  Becken,  nebst  einem  Anhang 
iiber  die  wichtigsten  Fehler  des  Weibl.  Beckens  Ueberhaupt,"  mit  16  Tafeln,  Mainz, 
1837- 


Fig.  345. — Obliquely  contracted  pelvis. 


ANOMALIES  IN  THE  FORCES  OF  LABOR.  479 

deformed  side  is  pushed  as  a  whole  upward,  backward,  and  inward, 
and  its  anterior  face  is  pushed  inward  and  backward.  The  tuber- 
osity of  the  ischium,  as  a  necessary  consequence  of  the  displace- 
ment of  the  innominate  bone,  is  higher  than  its  fellow,  projects 
further  into  the  pelvic  canal,  and  is  so  turned  that  it  looks  rather 
anteroposteriorly  than  laterally.  The  spine  of  the  ischium  is 
brought  quite  close  to  the  corresponding  edge  of  the  sacral  bone 
and  juts  prominently  forward  into  the  pelvic  canal.  The  whole  in- 
nominate bone  on  the  diseased  side  lacks  its  normal  curvature  at 
the  iliopectineal  line,  and  may  run  almost  straight  from  the  sacro- 
ihac  junction  to  the  symphysis  pubis.  The  opposite  innominate 
bone  has  a  greater  curvature  than  common,  especially  in  its 
anterior  half;  otherwise  it  is  practically  normal  in  structure, 
position,  and  inclination.  The  symphysis  pubis  is  pushed  toward 
the  healthy  side  of  the  pelvis,  and  its  outer  surface,  instead  of 
looking  directly  forward,  is  inclined  to  the  diseased  side.  The 
pubic  arch  likewise  faces  somewhat  in  this  direction  ;  its  aperture 
is  asymmetrical  and  irregularly  contracted,  as  the  ischiac  and 
pubic  rami  on  the  diseased  side  are  pushed  inward  upon  the 
pelvic  canal  and  over  toward  the  healthy  side  (Fig.  345). 

Etiology. — The  cause  of  the  obliquely  contracted  pelvis  under 
description  is  an  absence  of  the  bony  nuclei  in  the  ala  or  lateral 
process  on  one  side  of  the  sacrum.  The  lateral  process  conse- 
quently fails  to  develop,  and  the  innominate  bone  is  brought  in  re- 
lation with  the  bodies  of  the  sacral  vertebrae.  As  a  result,  there 
must  be  some  distortion  of  the  innominate  bone  even  in  fetal  and 
infantile  life,  but  this  is  increased  to  an  exaggerated  degree  when 
the  individual  begins  to  walk.  Instead  of  receiving  the  pressure 
from  the  lower  extremity  approximately  on  the  keystone  of  an 
arch,  as  does  a  normally  curved  innominate  bone,  the  deformed 
bone  in  a  Naegele  pelvis  transmits  the  pressure  in  almost  a 
straight  line  upward  and  backward,  so  that  the  extremity  of  the 
posterior  arm  of  the  arch  slides  past  the  sacro-iliac  joint  instead 
of  resting  firmly  on  it  as  an  arch  does  on  its  abutments.  The 
irritation  and  strain  of  this  unnatural  movement  bring  about  in 
time  the  atrophy  and  ankylosis  of  the  joint. 

That  the  deformity  in  this  kind  of  oblique  pelvis  does  not 
follow  a  primary  ankylosis  of  the  sacro-iliac  joint  is  proven  by 
the  fact  that  the  innominate  bone  is  pushed  backward  and 
upward  on  the  sacrum — a  movement  that  would  be  impossible 
were  this  joint  first  ankylosed.  As  a  further  proof  of  primary 
lack  of  development  and  secondary  ankylosis,  there  is  no  trace 
of  inflammation  in  or  about  the  ankylosed  joint,  and  the  alae  or 
transverse  processes  of  the  sacrum  are  atrophied  or  are  absent 
along  the  whole  length   of  the   sacrum,  and   not   only  in  that 


480  THE  PA  THOL  OGY  OF  LAB  OR. 

portion  of  it  which  enters  into  the  composition  of  the  sacro-iliac 
joint. 

Diagnosis. — The  recognition  of  an  obhquely  contracted 
pelvis  from  arrested  development  of  the  sacral  alae  may  be  very 
difficult.  There  is  nothing  to  direct  the  attention  of  the  phy- 
sician to  the  possibility  of  the  deformity.  There  is  no  history  of 
previous  disease  or  of  accident,  no  scar  of  an  old  fistula  over  the 
joint,  and  the  patient  does  not  limp.  The  diagnosis  can  be 
made  only  by  a  methodical  external  and  internal  palpation  of  the 
pelvis  and  by  careful  measurements.  If  the  outspread  hands  are 
laid  over  the  innominate  bones,  it  is  noticed  that  the  dorsal 
surfaces  are  directed  obliquely  forward  and  backward  as  they  lie 
upon  the  diseased  and  healthy  sides.  An  internal  palpation  of 
the  pelvis  detects  one  lateral  wall  much  nearer  the  median 
line  than  the  other,  and  the  diagonal  conjugate  is  found  to 
run  not  anteroposteriorly  in  direction,  but  from  before  backward 
and  from  the  healthy  to  the  diseased  side  of  the  pelvis.  There 
are  a  number  of  points  from  which  measurements  may  be  taken 
that  show  inequalities  where  in  the  normal  pelvis  the  dis- 
tances should  be  the  same  or  should  differ  by  a  very  small  sum. 
Naegele  recommended  the  following  measurements  :  (i)  The 
distance  of  the  tuber  ischii  on  one  side  from  the  posterior 
superior  spinous  process  of  the  ilium  on  the  other  ;  (2)  from  the 
anterior  superior  spinous  process  of  one  ilium  to  the  posterior 
superior  spinous  process  of  the  other ;  (3)  from  the  spinous 
process  of  the  last  lumbar  vertebra  to  the  anterior  superior 
spines  of  both  ilia ;  (4)  from  the  trochanter  major  of  one  side  to 
the  posterior  superior  spinous  process  of  the  opposite  iliac  bone  ; 
(5)  from  the  lower  edge  of  the  symphysis  pubis  to  the  posterior 
superior  spinous  processes  of  the  iliac  bones.  In  addition  to 
these  measurements,  others  of  value  have  been  suggested  by 
Michaelis  and  by  Ritgen.  These  are  the  distances  from  the 
middle  line  of  the  spinal  column  to  the  posterior  superior  spinous 
processes  of  the  iliac  bones,  and  the  distance  from  the  lower  edge 
of  the  symphysis  to  the  ischiac  spines,  and  from  these  spines  to 
the  nearest  point  on  the  edges  of  the  sacrum.  In  this  latter 
measurement  it  is  found  that  the  distance  from  the  symphy- 
sis to  the  ischiac  spine  is  longest  on  the  diseased  and  shortest  on 
the  healthy  side,  while  the  distance  from  the  ischiac  spine  to  the 
edge  of  the  sacrum  is  very  much  shorter  on  the  diseased  than 
on  the  healthy  side.  The  last,  which  is  a  very  important  meas- 
urement, can  easily  be  taken  by  la\'ing  finger-breadths  between 
the  points  to  be  measured.  As  in  all  anomalies  of  form  in  the 
female  pelvis,  an  x-ray  photograph  shows  the  condition  often 
surprisingly  well. 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


481 


Liflucnce  on  Labor. — The  mechanism  of  labor  in  an  obhquely 
contracted  pelvis  is,  in  the  main,  that  of  labor  in  a  generally 
contracted  pelvis.  The  shape  of  the  pelvic  entrance  and  canal 
is  symmetrically  ovoid,  and  the  head  can  enter  the  contracted 
space  only  by  extreme  flexion.  There  are  none  of  those  anoma- 
lies of  position,  flexion,  and  inclination  of  the  head  which  are 
seen  in  the  flat  pelvis.  As  the  head  descends  the  birth-canal, 
anomalies  of  mechanism  may  appear  resembling  those  described 
in    the    narrow,    funnel-shaped    pelvis — namely,    abnormal    and 


Fig.  346. — Pelvis  of  Naegele.      Reproduction  of  an  x-ray  photograph  taken  from  a 
hving  woman  (Budin). 


imperfect  rotation  and  anomalies  of  flexion.  Depending  upon 
the  degree  of  deformit}',  there  is  more  or  less  interference  with 
the  progress  of  labor  to  complete  obstruction.  The  head  is 
almost  invariably  found  entering  the  pelvis  and  passing  through 
the  canal  with  its  longest  diameter  in  coincidence  with  the 
longest  oblique  diameter  of  the  pelvis,  from  the  diseased  sacro- 
iliac joint  to  the  opposite  iliopectineal  eminence. 

Prognosis. — In  the  recorded  cases  the  results  of  labor  in  the 
Naegele  pelvis  have  been  bad.      Of  28  women  reported  by  Litz- 
mann,  22  died  in  their  first  labor,  5  of  them  undelivered.     Three 
31 


482  THE  PA THOLOG  V  OF  LABOR. 

of  these  women  died  in  consequence  of  their  second  labor,  and 
2  after  the  sixth.  Out  of  41  cases,  6  were  dehvered  spontane- 
ously, 12  by  the  forceps,  14  by  craniotomy,  5  by  version  and 
extraction,  4  by  premature  labor,  and  2  by  Cesarean  section. 
The  following  accidents  were  noted  in  the  course  of  labor  or 
shortly  afterward  :  Rupture  of  the  uterus  or  vagina,  vesico- 
vaginal fistula,  fracture  of  the  horizontal  ramus  of  the  pubis, 
rupture  of  the  sacro-iliac  joint  and  of  the  symphysis.  In 
another  series  of  cases,  28  women  furnished  forty-two  labors 
with  the  following  results  :  2 1  died  as  the  result  of  the  first 
labor,  3  of  the  second,,  and  i  after  the ,  sixth.  These  women 
were  delivered  seven  times  by  craniotomy,  once  by  Cesarean 
section,  four  times  by  premature  labor,  and  in  a  number  of 
instances  by  forceps.  Out  of  41  children  in  Litzmann's  statistics, 
there  were  only  10  delivered  alive,  2  of  these  by  Cesarean  section 
and  2  by  premature  labor.  The  6  other  living  children  were  all 
born  of  the  same  mother.  ^ 

TreaUnent. — Forceps  and  version  are  not,  as  a  rule,  success- 
ful in  the  treatment  of  labor  obstructed  by  an  obliquely  con- 
tracted pelvis  unless  the  degree  of  deformity  is  slight.  The 
induction  of  premature  labor  and  the  performance  of  Cesarean 
section  are  the  most  successful  means  of  delivery,  but  the  former 
should  be  resorted  to  only  when  the  distance  between  the  lower 
edge  of  the  symphysis  pubis  and  the  sacro-iliac  joint  of  the 
healthy  side  is  not  under  8.5  centimeters.  In  twenty  forceps 
operations  thirteen  women  died.  The  proposition  of  Pinard  to 
do  what  he  calls  ischiopubiotomy  has  not  met  with  favor.  The 
room  gained  by  the  movement  outward  of  the  innominate  bone 
on  the  healthy  side,  the  other  being,  of  course,  immovable,  will 
be  sufficient  only  in  pelves  so  slightly  contracted  as  to  allow  a 
delivery  by  much  simpler  means. 

Transversely  Contracted  Pelvis  the  Result  of  Imperfect  DeveU 
opment  of  Both  Sacral  Alse. — This  pelvis  was  first  described  in 
1842  by  Robert,  and  is  generally  known  as  the  "  Robert 
pelvis"  (Fig.  347).  It  is  the  rarest  of  all  contracted  pelves. 
Schauta  was  able  to  find  but.  six  examples  recorded  in  child- 
bearing  women.  Ferruta  has  reported  another  case.^  Herman 
gives  eight  as  the  number  of  recorded  cases;  Sonntag,^  nine.  The 
anatomical  conditions  are  the  same  as  in  the  Naegele  pelvis, 
except  that  both  sides  of  the  sacrum  are  affected  instead  of  one. 
Other  parts  of  the  sacrum  besides  the  alae  may  show  imperfect 
development.  There  is  a  case  reported  in  which  the  whole 
lower  portion  of  the  bone  was  absent.    The  sacrum  in  the  Robert's 

'  The  writer  is  indebted  for  these  statistics  to  Schauta  i^loc.  cit.). 
^  "  Studii  di  Ostetricia  e  GinecoL,"  Milan,  1890. 
^v.  Winckel's  "  Handbuch,"  2^,  p.  1959. 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


483 


pelvis  is  extremely  narrow,  and  the  posterior  superior  spinous 
processes  of  the  iliac  bones  are  brought  close  together.  The 
degree  of  contraction  in  the  transverse  diameter  is  so  extreme 
that  natural  labor  is  out  of  the  question.  An  asymmetry  of  the 
Robert  pelvis  has  been  observed,  one  side  showing  a  greater 
degree  of  the  deformity  than  the  other,  and  thus  approaching 
the  type  of  an  obliquely  contracted  pelvis. 

The  cause  of  this  deformity  is  an  absence  of  the  bony  nuclei 
in  the  sacral  al^e  of  both  sides.     Secondarily,  as  in  the  Naegele 


Fig.    347. — Transversely  contracted  pelvis:   C.  v.,  ()%  cm.;  tr.  (outlet),    5  cm.;  tr. 
(inlet),  8  cm.  (model  in  Miitter  Museum,  College  of  Physicians,  Philadelphia). 


pelvis,  there  is  usually  an  ankylosis  of  the  sacro-iliac  joints. 
That  this  ankylosis  is  secondary  and  not  primary  is  demonstrated 
by  the  same  condition  which  proves  that  ankylosis  is  not  a 
primary  cause  of  the  oblique  contraction  and  ill-development  of 
one  side  in  the  Naegele  pelvis — namely,  a  displacement  of  the 
ilia  on  the  sacrum  necessarily  occurring  before  the  ankylosis. 

The  treatment  of  labor  obstructed  by  a  transversely  contracted 
pelvis  of  this  kind  is  Cesarean  section. 

Justomajor  Pelvis. — A  generally  equally  enlarged  pelvis  is 
found  in  women  of  gigantic  stature,  but  it  may  also  occur  in  a 
woman  of  medium  height.  The  pelvis  of  the  Nova  Scotian 
giantess  was  large  enough  to  give  passage  to  a  child  weighing 
28^  pounds.  The  largest  pelvis  that  has  ever  come  under  my 
notice  was  found  in  a  woman  somewhat  below  the  average 
height,  without  an  abnormally  great  development  of  any  other 
portion  of  her  frame. 

Diagnosis. — The  diagnosis  of  a  justomajor  pelvis  is  made 
mainly  by  external  measurements.  If  all  of  them  are  found  far 
in  excess  of  the  normal  while  preserving  their  normal  relative 
proportion   the   diagnosis   of   a   justomajor  pelvis   is   justifiable. 


4^4  THE  PA  THOL  OGY  OF  LAB  OR. 

The  internal  examination,  if  considered  necessary,  shows  that 
the  promontory  is  quite  inaccessible,  and  that  it  is  much  more 
difificult  than  common  to  reach  the  lateral  pelvic  walls.  This 
anomaly  of  the  pelvis  does  not,  of  course,  obstruct  labor ;  on 
the  contrary,  it  predisposes  to  precipitate  delivery,  although  the 
resistance  of  the  soft  parts  may  be  quite  sufficient  to  delay  the 
process  considerably,  even  though  the  pelvis  present  no  obstacle 
whatever.  During  pregnancy  it  is  noted  that  the  uterus  has  a 
tendency  to  sink  deep  within  the  pelvic  canal,  so  that  pressure- 
symptoms  of  the  pelvic  viscera  and  blood-vessels  are  common 
in  the  latter  weeks  of  gestation,  and  these  symptoms  may  become 
so  exaggerated  as  to  make  locomotion  difficult.  In  labor  there 
may  be  anomalies  in  the  mechanism  dependent  upon  insufficient 
resistance  to  the  engagement  of  the  head.  Thus  imperfect  flexion 
at  the  superior  strait  may  be  observed,  and  there  may  be  a 
tardy  rotation  of  the  head  on  the  pelvic  floor. 

Split  Pelvis. — The  split  pelvis,  which  is  due  to  a  defect  in  the 
development  of  the  lower  portion  of  the  trunk  in  front,  is  almost 
invariably  associated  with  exstrophy  of  the  bladder.  This  pelvis 
has  very  rarely  been  observed  in  the  child-bearing  woman  ;  there 
are  on  record  but  seven  examples  complicating  labor.  The 
split  pelvis  presents  no  obstacle  in  parturition.  There  are 
the  same  peculiarities  in  labor  as  in  the  justomajor  pelvis — 
namely,  a  tendency  to  precipitate  birth,  and  anomalies  in  the 
mechanism  the  result  of  imperfect  resistance.  After  labor  it  is 
almost  certain  that  there  will  be  a  prolapse  of  the  uterus.  The 
diagnosis  of  this  deformity  presents  no  difficulties,  and  no  ob- 
stetic  treatment  is  called  for  in  labor  (Fig.  348). 

The  assimilation  pelvis  is  of  greater  interest  to  the  anatomist 
than  to  the  practical  obstetrician.  It  is  characterized  by  an 
assimilation  of  the  last  lumbar  vertebra  to  the  type  of  the  first 
sacral  vertebra  or  vice  versa.  The  anomaly  of  development  may 
affect  one  or  both  sides  of  the  vertebrae.  There  may  be  an  as- 
sociated double  promontory,  some  asymmetry  of  the  pelvis,  slight 
anomalies  in  the  transverse,  anteroposterior,  and  vertical  diame- 
ters of  the  pelvis,  but  not  enough  disturbance  of  pelvic  size  and 
shape  to  influence  labor  seriously.  According  to  Williams  this 
is  the  most  frequent  cause  of  the  funnel-shaped  pelvis.  It  is  only 
possible  to  diagnosticate  an  assimilation  pelvis  during  life  by  a 
careful  palpation  of  the  sacral  bones  in  a  vaginal  or  rectal  examina- 
tion.    It  is  not  often  practicable. 

The  Rachitic  Pelvis. — In  the  healthy  life  and  growth  of  bones 
two  opposed  processes  are  found  :  On  the  periphery  there  is  an 
active  proliferation  of  cells  to  form  the  bone-structure,  while  in 
the  interior,  bone-substance  is  being  constantly  absorbed  by  the 
marrow.      In  rachitis  the  absorption  of  bone-substance  goes  on 


ANOMALIES   IN  THE   FORCES   OF  LABOR. 


485 


more  rapidly  than  it  does  in  healthy  bone,  and  at  the  same  time 
there  is  in  the  periphery  a  very  much  more  rapid  proliferation  of 
cells,  which  do  not,  however,  develop  normal  bone-structure. 
Their  growth  and  multipHcation  result  in  the  formation  of  an 
osteoid  material  deficient  in  lime-salts  and  much  more  pliable  than 
healthy  bone.  The  result  of  this  pathological  process  in  the 
pelvic  bones  is  to  make  the  pelvis  yield  more  than  it  should  to 
the  mechanical  forces  that  are  brought  to  bear  upon  it. 

In  the  rachitic  pelvis  the  size  and  shape  of  the  pelvic  canal 


Fig.  348. — Split  pelvis  (Schauta). 

are  modified  by  three  factors  :  the  pressure  from  the  trunk  above 
and  the  counterpressure  from  the  extremities  below  ;  the  pull 
on  the  pelvic  bones  by  ligaments  and  muscles  ;  and  an  arrested 
development. 

Characteristics. — The   effect  of  rachitis   in   the  pelvic  bones 


Fig.  349. — Flat  rachitic  pelvis:  C.  v.,  5  I4;'  cm.;  effective  tiaiis.  diaiii.,  n  cm.  (Miit- 
ter  Museum,  College  of  Physicians,  I'hiladelphia). 

upon  the  shape  and  size  of  the  pelvic  canal  is  not  uniform. 
Several  varieties  of  contracted  pelvis  may  result.  The  com- 
monest is  the  flat  pelvis  with  some  contraction  of  all  the  diam- 


486 


THE  PATHOLOGY  OF  LABOR. 


eters,  but  a  most  marked  diminution  in  the  anteroposterior 
diameter  (Fig.  349).  There  may  be  found,  in  addition  to  this 
common  form,  a  simple  flat  rachitic  pelvis  without  alteration  of 
the  transverse  diameters,  a  generally  equally  contracted  rachitic 
pelvis  (Fig.  350),  and  a  so-called  "pseudo-osteomalacic"  pelvis, 
in  which  the  effect  seen  in  osteomalacia  is  produced  by  pressure 
upon  the  bones  softened  by  rachitis.  There  are  other  rare 
forms  of  asymmetrical  development,  in  connection  usually  with 
spinal  disease  of  rachitic  origin,  that  are  described  elsewhere. 


Fig-  35°- — Generally  equally  contracted  rachitic  pelvis  (author's  collection). 

Characteristics  of  the  Flat,  Generally  Contracted  Rachitic 
Pelvis. — The  sacrum  is  pressed  forward  and  downward  between 
the  iliac  bones,  and  is  rotated  on  its  transverse  axis,  mainly  by 
the  pressure  of  the  trunk  upon  it,  but  partly  by  the  pull  down- 


Fig.  351. — Flat  rachitic  pelvis,  with  unusual  descent  of  the  promontory,  rotation  of 
the  sacrum,  and  lordosis  (Mutter  Museum,  College  of  Physicians,  Philadelphia). 


ward  of  the  psoas  muscles  upon  the  spinal  column  and  the  pull 
upward  upon  the  posterior  surface  of  the  sacrum  by  the  erectores 


ANOMALIES  IN   THE   FORCES   OF  LABOR. 


487 


spinae  muscles  (Fig.  349).  The  effect  of  this  movement  would 
naturally  be  to  throw  the  tip  of  the  sacrum  and  the  coccyx 
directly  backward,  so  that  the  posterior  surface  of  the  sacral 
bone  would  run  an  almost  horizontal  course  as  the  woman  stood 
upon  her  feet.  The  attachments  of  the  sacrosciatic  ligaments 
and  muscles  to  the  lower  sacrum  and  coccyx,  however,  prevent 
this  backward  movement  of  the  bone  as  a  whole,  and,  pulling 
the  lower  portion  of  the  bone  forward,  cause  a  sharp  bend  in  it, 
usually  at  the  junction  of  the  fourth  and  fifth  sacral  vertebrse. 
The  sacrum  is  narrowed  in  its  transverse  diameter,  and  the 
lateral  concavity  of  the 
anterior  surface  is  effaced 
by  the  forward  movement 
of  the  bodies  of  the  verte- 
bra between  the  alae.  The 
anterior  surface  of  the  sa- 
crum, indeed,  may  be  con- 
vex from  side  to  side.  By 
the  pull  of  the  strong 
sacro-iliac  ligaments  run- 
ning from  the  sacrum  to 
the  posterior  superior  spi- 
nous processes  of  the  iliac 
bones  the  latter  are  pulled 
downward  and  forward  by 
the  descent  of  the  sacral 
promontory,  and  are  con- 
sequently made  to  ap- 
proach one  another  behind, 
but  they  do  not  keep  pace 
with  the  movements  of  the 
sacrum,  and  consequently 
project  more  prominently 
than  common  on  either 
side.  The  natural  result 
of  this  movement  forward 
and  inward  on  the  part  of 
the  posterior  superior  por- 
tions of  the  ilia  would  be 
to  throw  the  anterior  half 

of  the  innominate  bones  outward,  but  this  movement  is  opposed 
by  their  junction  at  the  symphysis,  and  to  a  less  degree  by  the 
attachment  of  Poupart's  ligament  to  their  anterior  superior 
spinous  processes.  The  ilia,  however,  restrained  by  a  somewhat 
yielding  force,  are  thrown  to  a  certain  degree  outward  and  back- 
ward, so  that  their  upper  edges  run  almost  horizontally  outward, 


F'g-  35-- — F'^t  rachitic  pelvis  with 
bowed  femora:  C.  v.,  5  cm.;  tr.,  \i)^  cm. 
(Mutter  Museum,  College  of  Physicians, 
Philadelphia). 


488  THE  PATHOLOGY  OF  LABOR. 

and  the  distance  between  their  anterior  spines  becomes  Uttle  less 
than,  the  same  as,  or  even  greater  than,  the  distance  between 
their  crests.  A  further  result  of  these  combined  forces  pulhng 
the  innominate  bones  inward  and  forward  behind  and  hold- 
ing them  in  place  in  front  is  to  produce  in  them  an  abnormal 
curvature,  as  in  the  case  of  the  sacrum,  or  as  in  a  bow  bent 
between  one's  hand  and  the  ground  (Fig.  353).  The  point  of 
angulation  or  greatest  curvature  is  found  on  the  ilio-pectineal 
line,  back  of  the  median  transverse  line  of  the  pelvic  inlet, 
near  the  sacro-iliac  joints.  On  account  of  the  flexion  of  the 
innominate  bones  the  transverse  diameter  of  the  rachitic  pel- 
vis is  relatively  increased,  but,  as  the  whole  pelvis  is  com- 
monly below  the  normal  in  size,  this  diameter  rarely  exceeds, 
if,  indeed,  it  equals,  the  normal  transverse  measurement.  A 
further  consequence  of  the  exaggerated  curvature  of  the  innom- 
inate  bones   is   to   throw   the    acetabula    forward,    so    that    the 


Fig.  353. — Schematic  representation  of  the  anterior  position  of  the  acetabula  in 
a  rachitic  pelvis.      The  pressure  of  the  femora  from  before  backward  contributes  to 

the  flattening  of  the  pelvis  (Schroeder). 

counterpressure  of  the  lower  extremities  is  exerted  more  antero- 
posteriorly  than  in  the  normal  pelvis  (Fig.  ^i^"^-)^-  '^^^^  pubic 
rami  and  the  symph\'sis  are  diminished  in  height  and  show  a 
lessened  slant  outward.  The  cartilage  at  the  junction  of  the 
symphysis  projects  inward  upon  the  pelvic  canal,  standing  out 
above  the  level  of  the  bones  to  such  a  degree  that  it  is  some- 
times a  source  of  injur}'  to  the  head  or  to  the  maternal  struct- 
ures. The  force  of  resistance  at  the  symphysis  to  the  outward 
movement  of  the  innominate  bones  sometimes  bends  the  ends 
of  the  pubic  bones  inward  upon  the  pelvic  canal,  giving  to  the 
pelvic  inlet  the  shape  of  a  figure  8.  From  the  traction  of  the 
adductor  and  rotator  muscles  of  the  thigh  upon  the  tuberosities 
of  the  ischiatic  bones  (increased  in  rachitis  by  the  positions  of  the 
acetabula  and  the  bowing  of  the  femora),  the  latter  are  pulled 
outward  and  forward  so  that  the  pubic  arch  is  greatly  widened 


ANOMALIES  IN  THE  FORCES  OF  LABOR.  489 

and  the  transverse  diameter  of  the  pelvic  outlet  is  increased. 
The  anteroposterior  diameter  of  the  outlet  is  somewhat  dimin- 
ished by  the  excessive  perpendicular  curvature  of  the  sacrum, 
but  the  contraction  is  relatively  much  less  than  in  the  conjugate 
of  the  inlet.  The  whole  pelvis  is  tilted  forward  on  its  transverse 
axis,  so  that  the  inclination  of  the  superior  strait  is  increased 
and  the  external  genitalia  are  displaced  backward. 

The  bones  of  a  rachitic  pelvis  are  usually  slighter  and  more 
brittle  than  common.  They  may,  perhaps,  show  no  peculiarities 
in  structure,  or  in  rare  cases  they  may  be  found  much  thicker 
and  heavier  than  normal. 

In  the  generally  equally  contracted  rachitic  pelvis — a  rare 
type — is  seen  mainly  an  arrest  of  development,  the  consequence 
of  rachitis  in  very  early  life,  which  retarded  growth  without 
much  affecting  the  shape  of  the  pelvic  inlet  and  canal,  from  the 


Fig.  354. — Pseudo-osteomalacic  pelvis. 

fact  that  the  pelvis  had  not  been  subjected  to  the  pressure  of  the 
trunk  during  the  active  stage  of  the  disease,  because  it  ran  its 
course  to  complete  recovery  before  the  child  attempted  to  sit  up 
or  to  walk.  Possibly,  also,  the  disease  in  some  of  these  cases  is 
not  severe  and  lasts  but  a  short  time.  As  the  deformity  is  the 
result  of  arrested  development,  a  transverse  contraction  is  found 
as  in  the  fetal  ill-developed  pelvis. 

The  diagnosis  of  the  rachitic  origin  of  this  type  of  pelvis  is 
made  by  the  relations  of  iliac  spines  to  crests,  perhaps  by  the 
history  of  rachitis  in  early  infancy,  and  possibly  by  the  signs  of 
the  disease  in  other  portions  of  the  body. 

In  the  pseudo-osteomalacic  pelvis  (F'ig.  354)  the  rachitis  has 
progressed  to  an  extreme  degree  and  has  been  long  continued. 
Efforts  to  walk  have  been   made  wiiile  the  disease  was  in  active 


490 


THE  PATHOLOGY  OF  LABOR. 


progress,  and  possibly  the  weight  of  the  trunk  has  been  exag- 
gerated by  attempts  to  carry  heavy  burdens.  As  a  consequence 
of  the  pressure  of  the  trunk  and  the  counterpressure  of  the 
lower  extremities,  the  pelvis  bends  under  the  forces  imposed 
upon  it.  The  sacrum  sinks  far  down  into  the  pelvic  canal  and  is 
sharply  curved  or  bent  from  above  downward  ;  the  innominate 
bones  are  bent  at  a  sharp  angle  laterally,  and  the  acetabula  are 

pressed  inward  upon  the  pel- 
vic canal.  When  at  length 
the  bone  disease  has  run  its 
course,  the  pelvis  is  firmly 
set,  by  the  hardening  of  the 
bones,  in  its  unnatural  posi- 
tion and  shape.  The  differ- 
ential diagnosis  between  this 
pelvis  and  the  true  osteo- 
malacic pelvis  is  made  by 
the  direction  of  the  iliac 
crests,  by  the  firm  constitu- 
tion of  the  bones  after  the 
disease  has  been  arrested, 
and  by  the  signs  of  rachitis 
in  other  portions  of  the 
bod}'.  Osteomalacia,  be- 
sides, has  certain  peculiari- 
ties of  its  own  that  enable 
one  to  recognize  it  without 
difficulty. 

Diagnosis. — The  diag- 
nosis of  a  rachitic  pelvis  is 
made  by  external  and  inter- 
nal measurements,  by  pal- 
pation of  the  exterior  and 
interior  of  the  pelvis,  by  the 
woman's  history,  and  by  her 
appearance.  An  individual 
who  has  had  rachitis  in 
childhood  is  usually  of  small  stature,  with  short,  thick,  cur\^ed 
extremities  ;  a  low,  broad  brow  ;  a  large,  square  head  ;  a  flat  nose  ; 
a  "  chicken  breast,"  and  enlarged  joints.  The  lumbar  lordosis  and 
the  rotation  of  the  sacrum  produce  a  sway-back,  most  noticeable 
when  the  woman  lies  on  her  back  upon  a  hard  surface.  When  she 
stands  erect  the  pregnant  uterus  near  term  falls  abnormally  for- 
ward and  downward,  on  account  of  the  short  abdomen  and  lack  of 
engagement  of  the  presenting  part  (Fig.  355).    The  mostcharac- 


Fii 


555. — Pendulous  belly  of  rachitis 
(Charpentier). 


ANOMALIES  IN  THE  EORCES  OF  LABOR. 


491 


teristic  facts  in  her  history  are  that  she  walked  first  at  three  or  four 
years  of  age  and  was  late  in  getting  her  teeth.  By  the  pelvimeter 
the  normal  relation  between  the  iliac  spines  and  crests  is  found 
disturbed.  The  difference  in  distances  between  the  former  and 
between  the  latter  is  much  reduced.  The  posterior  superior 
spinous  processes  are  approximated,  and  the  depression  under 
the  last  spinous  process  of  the  lumbar  vertebra  approaches  or  is 
actually  in  the  line  drawn  between  them.  The  external  antero- 
posterior diameter  of  Baudelocque  is  below  the  normal.      Inter- 


Fig.  356. — Appearance  during  life 
of  the  highest  grade  of  rachitis  ;  pseudo- 
osteomalacia  (Pippingskjold). 


Fig.  357.  —  Skeleton  of  a  rachitic 
dwarf  (Medical  Museum,  University 
of  Pennsylvania). 


nally,  the  diagonal  conjugate  is  found  considerably  reduced. 
The  symphysis  has  less  of  a  slant  outward  than  it  should  have  ; 
the  promontory  is  found  low  and  prominent  ;  the  sacral  bone  is 
sharply  bent  upon  itself,  and  the  pelvic  canal  is  remarkably 
shallow.  On  account  of  the  increase  in  the  conjugatosymphys- 
eal  angle  due  to  the  les.sened  slant  outward  of  the  sj-mphysis, 
at  least  two  centimeters  should  be  subtracted  from  the  diagonal 
conjugate.  The  difference  between  the  two  would  be  greater 
were  it  not  for  the  low  situation  of  the  promontory,  which  com- 
pensates to  a  certain  extent  for  the  lessened  slant  of  the  sym- 


492 


THE  PATHOLOGY  OF  LABOR. 


physis,  but  doe-s  not  entirely  neutralize  it.  If  a  double  promon- 
tory is  found,  which  in  these  pelves  is  not  uncommon  (Fig.  361), 
the  measurement  should  be  taken  from  the  promontory  nearest 
the  symphysis.  Occasionally  the  lordosis  of  the  lumbar  vertebrae, 
the  result  of  spinal  rachitis,  is  so  great  as  to  constitute  itself  an 
obstruction  above  the  pelvic  inlet.      In  such  a  case  the  effective 


Fig.  35^- 


-Rachitic  dwarf;   height,  4  feet,  I  inch.      Conj.  vera,  6  cm. 
section  (Howard  Hospital). 


Cesarean 


conjugate  must  be  taken  from  a  point  above  the  sacrum  to  the 
symphysis  pubis. 

Influence  on  Labor. — The  influence  of  a  flat  rachitic  pelvis  on 
labor  is  much  the  same  as  the  influence  of  a  simple  flat  pelvis, 
except  that  the  contraction,  and  consequently  the  obstruction  to 
labor,  is  greater  in  the  rachitic  form,  and  that  the  promontory  of 
the  sacrum  is  more  prominent  and  more  sharply  defined.  The 
anomalies  of  mechanism  at  the  inlet  are  the  same  in  both  varie- 
ties of  pelvis,  but  they  are  exaggerated  in  the  flat  rachitic  pelvis. 
As  soon  as  the  obstruction  at  the  inlet  is  overcome,  the  descent 


ANOMALIES  IIV  THE  FORCES  OF  LABOR. 


493 


Fig.  359. — Woman  with  congenital 
rachitis  (Ribemont-Dessaignes). 


Fig.  360. — Flat  rachitic  pelvis 
complicated  by  coxalgia.  Cesarean  sec- 
tion (seen  in  consultation  with  Dr. 
Geo.  I.  McKelway). 


Fig.  361. — Rachitic  pelvis  with  double  promontory :    C.  v.,  from  first  and  from 
id  sac.  vert.,  6^4  cm.  ;  tr.,  I2j^  cm.  (Mutter  Museum,   College  of  Physicians, 


second 
Philadelphia) 


494 


777^  PATHOLOGY  OF  LABOR. 


Fig.  362. — Pressure  of  the  pro  ^     pon  the  head  in  a  contracted  pelvis. 

(SmelHe). 


Fig.  363. — Overlapping  of  the  cranial  bones  in   a  futile  attempt  of  the  head  to 
engage  in  the  superior  strait  of  a  rachitic  pelvis  (Smellie). 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


495 


of  the  head  and  its  escape  are  more  rapid  in  the  rachitic  pelvis, 
because  of  the  shallow  canal  and  the  expanded  outlet.  Injuries 
to  the  child's  head  and  to  the  maternal  tissues  from  pressure  are 


Fig.  364. — Extreme  degree  of  osteomalacia  of  trunk  and  extremities  (Kaufmann). 

common.  In  the  former,  a  sharp  indentation  may  be  seen  on  that 
portion  of  the  skull  pressed  against  the  promontory  in  the  efforts 
to  secure  engagement,  the  so-called  "spoon-shaped"  depression, 
with  fracture  of  the  parietal  bone. 
Localized  necroses  are  not  infre- 
quently seen  in  the  maternal 
structures,  where  they  have  been 
nipped  between  the  child's  head 
and  prominent  portions  of  the 
pelvic  bones — namely,  in  the  cer- 
vical tissues  over  the  promontory, 
or  very  rarely  in  the  posterior 
vaginal  \'ault,  and  in  the  anterior 
vaginal  wall  behind  the  sxmphy- 
sis  and  the  ridge  of  the  pubic 
bones.  When  the  slough  sepa- 
rates, openings  may  be  estab- 
lished between  the  birth-canal  and  the  peritoneal  cavit}%  the  bowel, 
the  bladder,  and  a  ureter. 

Osteomalacic  Pelvis. — Osteomalacia,    a    soft    condition   of  the 


Fig.  365. — Schematic  representation  of 
ail  osteomalacic  pelvis  (Schroeder). 


496 


THE  PATHOLOGY  OF  LABOR. 


Fig.  366. — Minor  grade  of  osteomalacic  pelvis; 


bones  in  consequence  of  an  osteomyelitis  and  an  osteitis,  is  ex- 
ceedingly rare  in  America.  There  are  certain  parts  of  the  world 
where  it  is  frequently  seen,  notably  Italy,  Germany,  and  Austria, 
but  in  America  there  are  but  three  or  four  examples  on  record. 
The  bones  of  the  pelvis  in  this  disease  become  so  soft  that  they 

yield  to  every  force  imposed 
upon  them.  They  bend  be- 
fore the  pressure  of  the  trunk 
from  above,  the  extremities 
from  below,  and  the  pull 
of  the  muscles  attached  to 
the  pelvic  bones.  The  flexi- 
bility of  the  pelvis  in  extreme 
cases  of  osteomalacia  may 
be  appreciated  when  it  is 
stated  that  the  superior  iliac 
spines  may  be  bent  backward 
until  they  touch  the  spinal 
column  ;  the  horizontal  rami 
of  the  pubis  may  be  pushed  inward  until  they  almost  obliterate 
the  pelvic  inlet ;  and  the  tuberosities  of  the  ischium  may  be 
approximated  until  they  nearly  close  the  pelvic  outlet.  Not 
only  are  the  pelvic  walls  so 
compressed  that  they  almost 
obliterate  the  pelvic  canal, 
but  the  spinal  column  also, 
sinking  under  the  weight 
of  the  trunk,  bends  far  for- 
ward and  descends  low  into 
the  pelvis,  occupying  the 
little  remaining  room  in  the 
inlet  and  canal,  and  be- 
coming itself  a  serious  ob- 
struction to  the  engage- 
ment of  the  presenting  part. 
From  the  lateral  pressure  of 
the    thigh-bones   the    ischia 

and  pubes  are  pushed  inward  and  backward,  making,  by 
the  former  movement,  a  sharp  beak-like  projection  of  the 
pelvic  inlet  between  the  pubic  rami,  and  by  the  latter  much 
diminishing  the  size. of  the  pelvic  canal  (Figs.  365  and  366). 
The  sacrum  is  rotated  on  its  transverse  axis  and  is  driven 
far  down  into  the  pelvic  canal — an  exaggeration  of  the  move- 
ment seen  in  a  rachitic  pelvis.  The  lower  portion  of  the 
sacrum   and   the   coccyx   are  pulled   far    forward    by    the    mus- 


Fi£ 


367. —  Osteomalacia,    showing    asymme- 
trical contraction  at  outlet. 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


497 


cles  attached  to  them,  so  that  the  sacrum  is  bent  at  a  sharp  angle 
in  its  lower  third.  The  innominate  bones  are  bent  laterally  at  a 
point  slightly  anterior  to  the  sacro-iliac  junction,  and  the  iliac 
bones  m.ay  be  folded  upon  themselves  horizontally.  The  inclina- 
tion of  the  pelvis  as  a  whole 
is  much  increased. 

The  diagnosis  may  be 
based  upon  the  following 
symptoms :  The  disease 
begins  usually  during  preg- 
nancy or  lactation,  with 
dull  aching  pains  in  the 
extremities,  the  back,  the 
lumbar  region,  and  over 
the  anterior  portion  of  the 
pelvis.  Every  movement 
increases  these  pains.  As 
the  disease  progresses,  the 
bones  of  the  spinal  column 
are  so  bent  and  compressed 
that  the  individual  is  dimin- 
ished in  stature  to  an  extra- 
ordinary^ degree.  She  may 
lose  as  much  as  a  foot  and 
a  half  in  height  (Fig.  367). 
The  gait  of  an  osteomalacic 
patient  is  peculiar.  In 
order  to  compensate  for 
the  approximation  of  the 
thighs  brought  about  by 
the  collapse  of  the  pelvis, 
the  individual  must  turn 
almost  through  a  half-circle 
in  order  to  bring  one  foot 
in  front  of  the  other.  By 
palpation  of  the  pelvis  ten- 
derness upon  pressure  is 
discovered  over  its  anterior 
walls.  The  flexibility  of 
the    pelvic    bones   may  be 

demonstrated  by  direct  pressure,  and  an  internal  examination 
reveals,  in  the  early  stage  of  the  di.sease,  the  peculiar  beak-like 
space  behind  the  symphysis,  and  later  the  almost  entire  oblitera- 
tion of  the  pelvic  outlet  and  canal  by  the  sinking  in  of  the  pelvic 
walls.  If  it  is  possible  to  make  a  satisfactory  internal  examina- 
32 


F'g-  36s. — Author's  case  of  osteomalacia. 


49^  THE  PATHOLOGY  OF  LABOR. 

tion  of  the  pelvis,  the  low  position  and  the  projection  of  the 
promontory  at  once  attract  attention,  and  the  sharp  angulation 
on  the  anterior  face  of  the  sacrum  can  be  felt.  On  account  of 
the  exaggerated  inclination  of  the  pelvis,  it  may  be  necessary  to 
make  an  examination  with  the  patient  upon  her  side.  An  osteo- 
malacic pelvis  has  been  taken  for  a  kyphotic,  a  Robert,  a  pseudo- 
osteomalacic,  a  cancerous,  or  a  fractured  pelvis,  but  a  careful, 
methodical  examination  of  the  patient  should  always  lead  to  a 
correct  diagnosis. 

Influence  Upon  Labor. — The  results  of  labor  in  osteomala.cic 
pelves  show  that  the  obstruction  is  a  serious  one,  although  by 
reason  of  the  flexibility  of  the  pelvis  in  some  cases  the  head  can 
distend  the  pelvic  canal  sufficiently  to  pass  through.  In  85  cases 
collected  by  Litzmann,  47  ended  fatally.  In  another  series  of  128 
cases  the  labor  had  a  spontaneous  termination  in  27  cases,  in  4 
there  was  premature  delivery,  and  in  5  abortion  ;  4  times  the 
labor  was  naturally  terminated ;  in  8  cases  version  was  per- 
formed, in  4  the  child  was  extracted  by  the  feet,  in  25  forceps 
were  employed,  in  1 1  craniotomy  was  performed,  and  in  36 
Cesarean  section  ;  rupture  of  the  uterus  occurred  in  5  women . 
before  any  operation  was  undertaken.  In  still  another  series  of 
cases  reported  from  Milan,  the  flexibility  of  the  pelvis  was  so 
great  that  the  child  was  delivered  in  only  two  instances  by  Cesa- 
rean section. 

The  most  successful  treatme7it  is  the  performance  of  Cesarean 
section,  and  the  operator  should  at  the  same  time  remove  the 
ovaries,  or,  what  is  better,  perform  a  complete  Porro  operation.  It 
is  beyond  dispute  that  the  cessation  of  sexual  functions  favorably 
modifies  or  actually  cures  the  disease. 

Tumors  of  the  Pelvis. — The  commonest  pelvic  tumors  are 
bony  excrescences,  usually  found  over  one  of  the  pelvic  joints.^ 
The  excrescences  are  originally  cartilaginous  projections  which 
become  ossified  by  an  extension  of  bony  tissue  from  the  two 
bones  between  which  they  lie.  These  exostoses  may  be  found 
over  the  sacro-iliac  joints,  over  the  crests  of  the  pubis,  at  the 
iliopectineal  eminences,  and  over  the  promontory  of  the  sacrum 
(Figs.  370,  371,  372,  373).  They  may  attain  the  size  of  a  pigeon's 
sgg'  though  they  are  usually  not  larger  than  a  pea  or  nut.  In 
the  exostoses  occupying  the  seat  of  the  pubo-iliac  junctions, 
directly  above  the  acetabula,  the  bony  growth  is  apt  to  assume 
a  sharp,  thorny  shape,  projecting  with  its  point  into  the  pelvic 
inlet.  Kilian  was  the  first  to  direct  attention  to  this  fact  ; 
he  called  a  pelvis  thus  deformed  ''  acanihopelys"  (Fig.  374), 
or  a  ''pelvis  spinosa.'"     Another  possible  seat  for   a  bony  pro- 

1  Daniel  admits  only  four  authentic  cases  of  osteogenic  exostoses  complicating 
labor,  including  one  reported  liy  the  author.      "Annales  de  Gyn. ,"  August,  1903. 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


499 


jection  is  along  the  crests  of  the  pubic  bones,  the  exostosis 
taking  here  the  form  of  a  long,  sharp  edge,  and  probably  owing 
its  origin  to  an  ossification  of  the  attachment  of  the  iliac  fascia, 
a  transformation  of  tissue  analogous  to  the  ossification  some- 
times seen  in   Gimbernat's  ligament.      These   bony  outgrowths 


Fig-   369. — Cystic  enchondroma  Fig. 

(Zweifel). 


370. — Button-like  exostosis  on  the 
promontory  (Schauta). 


Exostosis  on  the  symphysis  (.Scliauta). 


are  a  serious  obstruction  in  labor,  not  so  much  from  their 
encroachment  upon  the  room  of  the  pelvic  inlet,  as  from 
the  sharply  localized  pressure  which  they  exercise  upon  the 
maternal  structures  and  upon  the  fetal  head.      In  the  four  cases 


500 


THE  PATHOLOGY  OF  LABOR. 


reported  by  Kilian,  death,  it  was  claimed,  resulted  in  each  case 
from  a  perforated  uterus.  Other  tumors  of  the  pelvis  obstruct- 
ino-  labor  are  enchondromata,  fibromata,  sarcomata,  carcino- 
mata,  and  cysts  (Figs.   369,  375).      These  tumors  are  rare,  and 


Fig.  372. — Exostoses  at  sacro-iliac  junctions. 


Fig.  373. — Exostoses  around  the  pelvic  brim  (model  in  the  author's  collection). 

their  importance  as  obstacles  in  labor  depends,  of  course,  upon 
their  size.  Cysts  of  the  pelvis  are  formed  usually  in  sarcomata 
and  in  enchondromata,  or  are  hydatid  cysts.  Cancer  of  the 
pelvic  bones  is  always  a  secondary  growth   or  is  metastatic.      It 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


501 


may  result  in  a  number  of  small  tumors  in  the  bony  pelvic  walls, 
or  may  take  on  the  form  of  cancerous  infiltration  with  a  conse- 
quent softening  of  the  bones  like  that  of  osteomalacia.  The 
treatment  of  labor  obstructed  by  tumors  of  the  pelvis  is  ordi- 
narily the  performance  of  Cesarean  section.  There  is  one  case 
on  record  (Abernethy's)  in  which  the  tumor,  an  enchondroma, 
was  removed  by  an  incision  in  the  posterior  vaginal  wall,  but  in 
the  vast  majority  of  cases  these  growths  can  not  be  reached  or 


Fig.  374. — Acanthopelys. 


Fig.  375. — Enchondroma  (Rehni). 


safely  excised.  In  49  cases  of  labor  obstructed  by  a  pelvic 
tumor,  50  per  cent,  of  the  women  and  90  per  cent,  of  the  children 
lost  their  lives  (Winckel). 

Fractures  of  the  Pelvis. — Out  of  13,200  fractures  reported 
from  nine  large  hospitals  in  America  and  in  Europe,  but  -f-^  of  one 
per  cent,  were  fractures  of  the  pelvis.  When  one  considers  that 
almost  all  grave  injuries  of  the  pelvis  end  fatally,  the  rarity  of  a 
pelvic  deformity  dependent  upon  a  united  fracture  of  a  pelvic 
bone  in  a  woman  of  child-bearing  age  may  be  appreciated.      Most 


502 


THE  PATHOLOGY  OF  LABOR. 


frequently  the  fracture  is  found  in  the  pubes,  next  in  the  ilium, 
next  in  the  ischium,  next  in  the  acetabulum,  and  least  frequently 
of  all  in  the  sacrum.  The  effect  of  a  fracture  of  the  pelvis  upon 
the  shape  and  size  of  its  canal  depends  on  the  location  of  the 
fracture.  The  deformity  may  be  due  to  distortion  of  the  pelvic 
walls,  to  excessive  callous  formation,  or  to  ossification  of  the  pelvic 
joints  nearest  the  seat  of  fracture.  In  a  fracture  of  the  acetabu- 
lum the  result  of  hip-joint  disease,  the  head  of  the  femur  may 


Fig. 


-Fracture  of  the  pelvis  (Otto). 


Fig.   377' — Praciure  of  the  acetabulum  in  consequence  of  coxalgia  (Otto) 


project  into  the  pelvic  canal  (Fig.  377).  F"racture  of  the  pubes 
results  in  an  irregular  distortion  of  the  pelvic  inlet,  most  marked, 
of  course,  on  the  injured  side  (Fig.  ^"/(i)-  A  fracture  of  the  upper 
portion  of  the  sacrum  ma}'  result  in  a  spoil d}'lolisthetic  deform- 
ity (Fig.  378).  Fracture  of  the  lower  portion  of  the  sacrum  is 
followed  by  a  dislocation  of  the  lower  fragment  inward.  In  a 
case  under  my  obser\'ation  the  lower  half  of  the  sacral  bone  was 
turned  in  at  right  angles  to  the  rest  of  the  bone  by  the  pull  of 


AiXOMALIES  IN  THE  FORCES  OF  LABOR.  503 

the  pelvic  muscles  attached  to  it.  A  fracture  of  the  sacral  alae 
may  cause  an  oblique  contraction  of  the  pelvic  inlet  like  that  of 
the   Naegele   pelvis    (Fig.  379).      Neugebauer^   reported  an  ex- 


Fig.  378. — Transverse  fracture  of  the  sacrum  with  spondylolisthetic  deformity 

(Neugebauer). 


Fig.  379. — Fracture  of  the  right  ala  of  the  sacrum  (Fritsch). 

traordinary  case  of  bilateral  fracture  of  the  pubic  rami  in  which 
there  was  union  with  callous  formation  on  one  side  and  an  ununited 

1  "  Jahresbericht  iiber  d.  Fortschr.  a.  d.    Ciebiete  der  Gei)urtsh.,"  etc.,  vol.  iv, 
p.  188. 


504  THE  PATHOLOGY  OF  LABOR. 

fracture  on  the  other,  the  fragments  moving  on  each  other  two 
or  three  centimeters  when  the  woman  walked. 

Caries  and  Necrosis. — The  only  effect  of  these  diseases  of  the 
pelvic  bones  is  the  production,  in  rare  cases  of  tuberculosis  of  a 
sacro-iliac  joint,  of  an  oblique  contraction  of  the  pelvis.  When 
the  sacro-iliac  joint  is  affected,  the  ultimate  result  is  the  same  as 
that  produced  by  imperfect  development  of  the  sacral  ala  in  a 
true  Naegele  pelvis.  There  is  loss  of  tissue,  ankylosis  of  the 
joint,  and  an  arrest  of  development  in  the  affected  part  if  the 
disease  occurs  in  early  childhood. 

Ankylosis  and  Relaxation  of  the  Pelvic  Joints. — Synostosis 
-may  develop  in  any  of  the  pelvic  joints  ;  in  the  symphysis  it 
occurs  not  infrequently,  and  often  at  an  early  age.  A  number 
of  operators  have  encountered  difficulty  on  this  account  in  at- 
tempts to  perform  symphysiotomy.  In  otherwise  unobstructed 
labor  synostosis  of  the  pubic  symphysis  is  not  a  serious  condi- 
tion, although  it  limits  the  slight  expansion  which  every  normal 
pelvis  should  exhibit  preparatory  to  and  during  labor. 

If  synostosis  of  the  sacro-iliac  joint  develops  in  the  indi- 
vidual's early  childhood,  it  is  followed  by  ill-development  of  the 
sacral  alae  on  the  affected  side,  and  of  that  portion  of  the  in- 
nominate bone  concerned  in  the  formation  of  the  joint,  an 
obliquely  contracted  pelvis  of  the  Naegele  type  being  the  result ; 
but  such  cases  are  rarer  than  those  in  which  lack  of  development 
in  the  sacral  alae  is  the  primary  occurrence.  If  the  synostosis 
of  the  joint  occurs  after  puberty,  the  effect  upon  the  pelvis  and 
upon  the  course  of  labor  is  practically  nil.  If  both  joints  are 
early  ankylosed,  a  form  of  laterally  contracted  pelvis  like  the 
Robert  pelvis  is  the  result.  This  kind  of  contracted  pelvis  is 
rarer  than  the  transversely  contracted  pelvis  due  primarily  to  lack 
of  development  in  the  sacral  alae. 

The  sacrococcygeal  joint  becomes  ankylosed,  as  a  rule, 
between  the  thirtieth  and  fortieth  years,  but  as  the  joint  between 
the  first  and  second  coccygeal  vertebrae  is  ordinarily  unaffected, 
the  pelvic  outlet  is  capable  of  expansion  during  labor  in  its 
anteroposterior  diameter  nearly  as  well  as  if  the  sacrococcygeal 
joint  were  normal.  Rarely,  there  is  an  ankylosis  of  all  the  coc- 
cygeal joints  as  well  as  of  that  between  the  sacrum  and  the  coc- 
cyx. In  these  cases  labor  can  be  terminated  only  by  a  fracture 
of  the  coccyx  or  a  rupture  of  a  coccygeal  joint,  usually  the  first. 
The  expulsive  forces  of  labor  may  be  sufficient  to  cause  the 
fracture,  and  the  bone  has  been  heard  to  give  way  with  a  loud 
crack  as  the  head  was  passing  through  the  pelvic  outlet.  This 
accident,  however,  is  more  likely  to  be  caused  by  the  artificial 
extraction  of  the  head. 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


:)^D 


An  abnormal  relaxation  of  the  pelvic  joints  may  be  a  simple 
exaggeration  of  the  natural  process  by  which  the  pelvic  canal 
is  made  somewhat  expansible  preparatory  to  labor.  It  is  more 
likely,  however,  to  be  due  to  some  pathological  condition  within 
the  pelvic  joints,  as  an  inflammatory  process  followed,  perhaps, 
by  suppuration,  an  accumulation  of  fluid  within  the  joint,  osteo- 
malacia, caries,  or  new  growths.  In  pregnancy  the  pathological 
relaxation  of  the  pelvic  joints  may  occasion  some  difficulty  in 
locomotion.  During  labor  an  exaggerated  relaxation  of  the 
joints  predisposes  to  their  rupture. 

The  Spondylolisthetic  Pelvis. — The  spondylolisthetic  pelvis 
was  first  described  in  1839  by  Rokitansky,  who  reported  two 
cases  ;  Kiwisch  and  Kilian  each  followed  with  a  description  of  a 
specimen  ;  but  we  owe  our  knowledge  of  the  condition  mainly 
to  the  indefatigable  researches  of  Neugebauer,  ^  who  collected 
more  than  one  hundred  cases  and  specimens,  and  to  the  discov- 
eries of  Lane,  who  has  done  much  to  clear  up  the  etiology.  The 
name  "  spondylolisthesis  "  ^  indicates  the  condition — a  slipping 
down  or  dislocation  of  the  vertebrae.  To  affect  the  pelvis  the 
spondylolisthesis  must  be  in  the  lumbosacral  region  (Figs.  380- 

Characteristics. — As  the  name  denotes,  there  is  a  dislocation 
of  the  last  lumbar  vertebra  in  front  of  the  sacrum,  the  body  of 
the  former  slipping  down  in  front  of  the  first  sacral  vertebra,  so 
that  its  inferior  border,  or  in  advanced  cases  its  anterior  surface, 
comes  in  contact  with  the  anterior  face  of  the  sacrum,  to  which 
it  becomes  united  by  bony  union.  There  is,  also,  of  necessity, 
an  exaggerated  lordosis  of  the  lumbar  vertebree  and  a  descent 
into  the  pelvic  inlet  of  at  least  the  fourth  and  third,  and  even  of 
the  second,  lumbar  vertebrae,  which  diminish  by  their  bulk  and 
anterior  projection  the  anteroposterior  diameter  of  the  peK'ic 
canal.  It  is  only  the  body  of  the  last  lumbar  vertebra  that  is 
displaced,  and  not  the  arch,  held  fast  by  the  lower  posterior 
articular  surfaces,  nor  the  laminae  surrounding  the  spinal  cord  ; 
so  that  the  latter  does  not  necessarily  suffer  compression  by  the 
displacement  of  the  vertebrae,  although  this  result  has  been  noted 
in  a  few  cases   (Fig.   381),      To   allow  the  displacement   of  the 

1  Franz  Ludwig  Neugebauer,  "  Bericht  iiber  die  neueste  Kasuistik  und  Littera- 
tur  der  Spondylolisthesis,"  etc.,  "  Zeitschrift  f.  Geburtshiilfe  und  Gynakologie," 
Bd.  xxvii,  II.  2,1893;  "Spondylolisthesis  et  Spondylizi^me,"  "  Resume  des  Re- 
cherches  litteraires  et  personelle  depuis  l88o  jusqu'en  1892,''  Paris,  G.  Steinlieil, 
1892  ;  "  Contribution  a  la  Pathogenie  et  au  Diagnostique  du  Bassin  vicie  ]iar  le 
Glissement  vertebral,"'  '■  Annales  de  Gynecologie,"  I'd).,  1884;  "  Zur  Entwicke- 
lungsgeschichte  des  .spondylolisthetischen  Beckens  und  seiner  Diagnose,"  Halle  and 
Dorpat,  1882,  p.  294;  see  also  "  Archiv  f.  Gynakologie,"  Bd.  x.\,  H.  i,  und  Bd. 
xxi,  H.  2.  The  best  article  in  English  is  by  J.  Whitridge  Williams,  "  Tr.  Am.  Gyn. 
Society,"  vol.  xxiv,  1899,  with  full  bibliography  to  date. 

2(7— 6i'(5v/.of,  vertebra,  and  (j'/iaHijoir,  a  sii|)|)ing  out  or  down. 


5o6 


THE  PATHOLOGY  OF  LABOR. 


body  of  the  last  lumbar  vertebra  the  interarticular  segment  of 
the  spinal  arch  and  the  pedicles  are  enormously  lengthened  from 
behind  forward  and  are  bent  at  an  angle  downward  (Fig.  381). 
After  a  time  this  segment  may  exhibit  a  transverse  fracture  or  a 
solution  of  continuity  from  pressure  and  attrition.  The  deform- 
ity is  always  gradual  in  development.  If  it  begin  during  the 
child-bearing  period,  successive  labors  become  increasingly  diffi- 
cult.    As  the  vertebra  descends,  it  pushes  the  sacrum  backward 


in) 


Fig.  380. — Spondylolisthesis,  well  marked 
(Schauta) . 


Fig-     381. — Spondylolisthesis, 
beginning  (Schauta). 


Fig.  382. —  Last  lumbar 
vertebra  of  spondylolisthesis  ((?), 
contrasted  with  a  normal  fifth 
lumbar  vertebra  (Neugebauer). 


and  downward,  and  with  it  depresses  the  posterior  portion  of  the 
pelvic  brim.  To  compensate  for  this  movement  the  anterior 
half  of  the  pelvic  brim  rises  and  the  height  of  the  symphysis 
is  increased.  This  movement  of  the  pelvis  diminishes  very 
markedly  its  inclination,  and  disturbs  the  normal  relationship 
between  the  bones  and  the  soft  structures  that  overlie  them. 
The  base  of  the  triangle  formed  by  the  pubic  hair  in  women  is 
well  below  the  upper  edge  of  the  symphysis,  and  the  external 
genitalia  are  pulled   so  far    forward    that    the  vulvar    orifice  is 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


507 


directed  anteriorly  as  the  patient  sits  or  stands.  There  are,  more- 
over, the  same  displacements  of  the  pelvic  bones  that  are  seen  in 
kyphosis — a  rotation  backward  of  the  sacrum  on  its  transverse 
axis  ;  a  rotation  outward  of  the  upper  portions,  and  inward 
of  the  lower  portions,  of  the  innominate  bones  on  their  antero- 
posterior axes.  The  descent  of  the  lumbar  vertebrai  drags  the 
large  arteries  of  the  lower  trunk  into  the  pelvic  inlet,  so  that  the 
iliac  vessels  and  the  bifurcation  of  the  aorta  may  be  felt  in  a 
vaginal  examination.  The  degree  of  contraction  in  the  conjugate 
diameter  of  the  inlet  depends  upon  the  descent  of  the  last  lumbar 
vertebra  and  the  degree  of  the  lordosis.  The  contraction  is  usu- 
ally not  excessive,  but  it 
may  be  so  great  as  to  pre- 
clude the  possibility  of  the 
engagement  of  the  fetal 
head. 

Etiology. — The  etiology 
of  spondylolisthesis  at  the 
lumbo-sacral  junction  is 
still  obscure.  It  has  been 
attributed  to  direct  injuries 
of,  and  to  faults  of  devel- 
opment or  ossification  in, 
the  interarticular  segments 
of  the  spinal  arch.  It  is 
certain  that  these  are  pre- 
disposing causes,  but  the 
observations  of  Lane  ap- 
pear to  demonstrate  that 
the  commonest  cause  of  the 
deformity  is  an  exaggerated 
pressure  from  the  trunk 
above  exerted  often  upon 
healthy  bone.      As  a  result 

of  this  pressure  a  joint  is  formed  in  the  intervertebral  disc,  and  the 
interarticular  segments  of  the  last  lumbar  vertebra  undergo 
stretching,  pressure,  angulatit)n,  and  atrophy  until  the  bone  is 
actually  severed.  Following  or  accompanying  these  changes  in 
the  arch,  the  body  of  the  last  lumbar  vertebra  is  gradualh'  dis- 
placed downward  and  forward.  Spondylolisthesis  has  followed 
an  injury,  presumably  a  fracture,  of  the  lumbar  vertebra:. 

Frequency. — Neugebauer  collected  i  i  5  cases,  to  which  num- 
ber Williams  added  8.  The  author  has  .seen  one  case  in  a  single 
woman,  aged  59  (Fig.  383).      Of  the  124  cases,  8  were  in  men. 

Diagnosis. — The  diagnosis  of  a  spondylolisthetic  pelvis  is  not 


Fig.    383. — Author's  case  of  spondylolislhesis. 


508 


THE  PATHOLOGY  OF  LABOR. 


easy  ;  it  can  be  made  only  by  close  attention  to  the  patient's 
history,  by  a  careful  observation  of  her  appearance,  by  an  inter- 
nal and  external  examination  of  the  pelvis,  and  by  pelvimetry. 
In  the  history  of  the  case  it  may  appear  that  the  individual  was 
the  subject  of  a  serious  accident,  such  as  a  fall  from  a  height  or 
a  fracture  of  the  pelvis  by  the  passage  over  it  of  a  heavy  weight, 
or  it  may  be  learned  that  she  has  carried  excessively  heavy  bur- 
dens for  a  long  time.  The  woman's  height  is  diminished  and 
the  length  of  the  abdomen  is  shortened.  Viewing  the  patient 
from  behind,  there  appears  what  is  called  the  saddle-shape  or 
"sway"  back,  the  lumbar  vertebrae  projecting  visibly  far  forward 
and   being   displaced   downward,   throwing  into   bold    relief  the 


Fig.    3S4. — Breisky's  case  of  spondylolisthesis. 

posterior  superior  spinous  processes  and  the  rims  of  the  iliac 
bones,  and  producing  quite  a  deep  furrow  along  the  course  of 
the  spinous  processes  of  the  lumbar  vertebrae.  The  apposed 
articular  processes  of  the  first  sacral  and  the  last  lumbar  verte- 
brae stand  out  as  button-shaped  prominences  on  the  inner  surface 
of  the  posterior  rims  of  the  ilia.  The  buttocks  are  flat  and  are 
pointed  below,  giving  to  the  region  a  cordiform  appearance.  In 
front  there  is  a  pendulous  belly;  a  deep  crease  is  observed  run- 
ning across  the  lower  abdomen  a  short  distance  above  the  sym- 
physis. Laterally,  the  floating  ribs  are  seen  almost  to  rest  upon 
the  crests  of  the  ilia  or  actually  to  sink  between  them,  and  the 
soft   structures   of  the    flanks   are  thrown  outward  in  prominent 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


509 


folds.  The  trunk  is  shortened,  and  the  hmbs  appear  relatively 
too  long  (Fig.  384).  The  patient's  body  being  thrown  forward 
by  the  deformity  of  the  spine,  an  effort  to  maintain  an  equilib- 
rium is  made  by  carrying  the  shoulders  far  back;  as  the  individual 
walks,  a  disposition  to  fall  forward  may  be  noted,  and  she  states, 
perhaps,  that  she  is  unable  to  carry  any  load  upon  her  arms  in 
front  of  her  bod\',  for  fear  of  toppling  over  upon  her  face.  She 
may  also  complain  of  pain  or  of  a  grating  sensation  and  sound 
in  the  small  of  the  back  (crepitus).  The  gait  is  peculiar  ;  the 
toes  are  not  turned  out,   and  the  feet  are  swung  around  each 


Fig.  385. — Footprints  of  author's  case  of  spondylolisthesis. 


other  so  that  the  footprints  fall  in  a  straight  line  (Fig.  3S5).  Upon 
an  internal  examination  of  the  pelvis, — best  conducted,  accord- 
ing to  Neugebauer,  in  an  upright  or  lateral  position, — the  lordosis 
of  the  lumbar  vertebrae  is  at  once  discovered.  The  angle  formed 
by  the  attachment  of  the  last  lumbar  vertebra  to  the  sacrum 
may  be  detected  with  ease,  especially  in  a  rectal  examination, 
and  it  should  be  noted  that  the  body  of  this  vertebra  does  not 
possess  lateral  projections,  transverse  •  jirocesses,  or  alas.  By 
their    absence    the    bone    is    distinguished    from    a    projecting 


5  I O  THE  PA  THOL  OGY  OF  LAB  OR. 

promontory.  Pulsating  iliac  arteries  may  be  felt,  and  it  is  pos- 
sible even  to  reach  the  bifurcation  of  the  aorta, — as  first  pointed 
out  by  Olshausen, — but  this  symptom  is  not  pathognomonic.  It 
is  possible  to  reach  the  bifurcation  of  the  aorta  in  a  vaginal  exam- 
ination in  the  extreme  lordosis  of  some  rachitic  pelves  and  of  the 
osteomalacic  pelvis,  in  lumbrosacral  kyphosis,  and  in  some  cases 
of  dorsolumbar  kyphosis. 

The  external  palpation  of  the  pelvis  demonstrates  the  absence 
of  inclination.  A  measurement  of  the  pelvis  may  show  a 
diminution  in  the  external  conjugate  diameter,  an  increased 
height  in  the  symphysis  pubis,  an  increased  distance  between  the 
posterior  superior  iliac  spines,  and  a  diminished  distance  between 
the  anterior  iliac  spines  and  the  crests.  The  external  conjugate 
may  not  be  decreased  at  all  ;  it  may  even  be  increased  if  meas- 
ured from  the  top  of  the  sacrum,  which  is  pushed  backward. 
There  is  some  diminution  in  the  diameters  of  the  outlet. 
The  internal  conjugate  diameter  must  be  measured  from  the 
lumbar  vertebra  nearest  the  symphysis  pubis,  usually  the  fourth. 
This  is  called  the  "false"  or  "effective"  conjugate  diameter  of 
the  spond}'lolisthetic  pelvis.  On  account  of  the  decreased  in- 
clination of  the  pelvis  it  is  not  necessary  to  subtract  more  than 
the  ordinary  sum  from  the  diagonal  conjugate.  In  fact,  the 
diagonal  conjugate  may  approach  very  nearly  the  length  of  the 
true,  or  may  actually  measure  less. 

Influence  Upon  Labor. — The  influence  of  a  spondylolisthetic 
pelvis  upon  labor  is  that  of  a  flat  pelvis.  The  obstruction  in 
the  former  may  be  overcome  more  easily  on  account  of  the  bow- 
like shape  of  the  projecting  vertebra  and  the  coincidence  of  the 
uterine  and  pelvic  axes.  The  obstruction  to  labor  depends 
entirely  upon  the  projection  of  the  lumbar  vertebrae.  This  pro- 
jection may  be  so  slight  as  scarcely  to  influence  the  progress  at 
all,  or  it  may  be  so  great  as  to  make  delivery  by  the  natural 
channel  quite  impossible.  There  is  noticed  in  labor  something- 
of  the  same  mechanism  that  is  seen  in  the  flat  pelvis  for  the  pur- 
pose of  overcoming  the  obstruction — namely,  decreased  flexion, 
transverse  position,  and  exaggerated  lateral  inclination  of  the 
head.  On  account  of  the  forward  dislocation  of  the  external 
genitalia  and  of  the  pelvic  floor,  lacerations  of  the  latter  are  the 
rule,  and  the  tears  are  often  complete  into  the  rectum.  This 
liability  to  injury  is  explained  by  the  fact  that  the  presenting 
part  impinges  directly  upon  the  middle  of  the  pelvic  floor  as  it 
descends  the  birth-canal,  instead  of  being  directed  forward  to  the 
vuK'ar  orifice.  Fistulse  of  the  anterior  vaginal  wall  are  likewise 
common,  from  the  localized  pressure  to  which  this  region  is 
subjected  while  the  head  is  passing  the  obstruction  at  the  inlet.. 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


511 


The  presenting  part  is  thrown  forward  by  the  projecting  ver- 
tebrae, and  IS  received  upon  the  prominent  ridge  of  the  pubic 
bone,  greater  in  height  and  higher  in  situation  than  in  the  nor- 
mal pelvis. 

Treatment  of  Labor  Obstructed  by  SpondylolistJietic  Pelvis. — 
The  management  of  labor  in  these  cases  is  governed  by  the  same 
principles  that  obtain  in  the  management  of  labor  in  a  flat  pelvis. 
If  the  effective  conjugate  is  over  9.5  cm.,  the  woman  can  be 
delivered  spontaneously,  by  forceps,  or  by  version.  With  an  ef- 
fective conjugate  of 
7  to  9.5  cm.,  the  in- 
duction of  prema- 
ture labor  and  the 
performance  of 
symphyseotomy  ^ 
might  be  con- 
sidered ;  or  cranio- 
tomy should  be 
done  if  the  child 
is  dead.  If  the 
effective  conjugate 
is  at  or  under  7 
cm.,  delivery  must 
be  effected  by  a 
Cesarean  section. 
These  rules  pre- 
suppose, of  course, 
a  child  of  average 
size. 

After  the  wo- 
man's convales- 
cence from  her 
delivery  she  should 
be  referred  to  an 
orthopedic  surgeon 

for  the  adjustment  of  a  brace  which  makes  her  more  comfortable 
and  might  retard  the  progress  of  her  disease. 

Kyphosis. — The  kyphotic  pelvis  was  first  adequately  described 
in  1865  by  Breisky,  although  its  peculiarities  had  been  recog- 
nized by  Litzmann  in  1861  and  by  Neugebaucr  in  1863.  The 
condition  was  called  by  Herrgott  "spondylizema,"  a  name 
adopted  by  Neugebauer  and  others  (Figs.   387,  38S). 

'  Symphyseotomy  has  been  performed  twice  for  spondylolisthesis  by  Morisani  and 
Williams.  Both  operations  were  fatal.  The  effective  conjugate  is  apt  to  be  less  than 
it  seems,  so  that  in  case  of  doubt  as  to  the  measurement  Cesarean  section  should  be 
performed. 


Fig.  386. — Angulation  of  the  spine  in  kyphosis. 


512 


THE  PATHOLOGY  OF  LAB  OP. 


Characteristics. — The  degree  of  deformity  in  a  kyphotic  pel- 
vis depends  upon  the  situation  of  the  hump  :  the  nearer  this  is 
to  the  sacrum,  as  a  rule,  the  greater  is  the  deformity  in  the 
pelvis.  Lumbosacral  kyphosis  is  almost  as  frequent  as  the 
lumbar  and  dorsolumbar  combined.  There  is  a  compensating 
lordosis  of  the  lumbar  spine,  but  not  enough  to  keep  the  center 
of  gravity  of  the  trunk  from  being  too  far  forward.      In  conse- 


-Kyphotic  pelvis  from  above 
(Barbour). 


Fig.  388. — Contracted  outlet  of  a  kyphotic 
pelvis  (Barbour). 


Fig.  3S9. — Kyphosis  :  greatest 
transverse  diameter  at  outlet,  7  cm. 
(Miitter  Museum,  College  of  Physi- 
cians, Philadelphia). 


quence,  the  weight  of  the  trunk  is  transmitted  in  a  direction  from 
before  backward,  so  that  the  sacrum  is  rotated  on  its  transverse 
axis  in  a  direction  the  reverse  of  that  seen  in  rachitis — namely, 
backward  and  scarcely  at  all  downward.  The  result  of  this 
movement  is  to  make  the  sacrum  straighter,  narrower,  more 
curved  from  side  to  side,  and  longer  (Fig.  387) ;  to  pull  the  pos- 
terior superior  spinous   processes  of  the   iliac  bones   closer  to- 


Plate  h. 


I,  Lumbodorsal  kyphoscoliosis  (Schauta)  ;  2,  lordosis  from  paralysis  of  spinal  muscles 
(author's  case)  ;  3,  skeleton  of  a  girl  with  co.\ali,Ma  (Medical  Museum,  University  of  Penna.)  ; 
4,  rear  view,  5,  side  view,  of  obliquely  contracted  pelvis, the  result  of  tuberculous  disease  in  one 
knee-joint  (author's  case) ;  6,  scoliosis  from  unilateral  atrophy  of  spinal  muscles  (author's  case). 


AXOMALIES  IN  THE  FORCES  OF  LABOR. 


513 


gether,  and  to  separate  the  anterior  spines  more  widely.  The 
diminished  width  between  the  posterior  superior  spinous  pro- 
cesses is  caused  partly  by  the  pull  of  the  sacro-iliac  ligaments. 
The  sacrum  can  not  move  in  any  direction  without  dragging  the 
ilium  on  each  side  by  these  ligaments,  thus  approximating  their 
upper  posterior   surfaces.      The   diminution   of  the   interspinous 


Fig.  390.— Lumbosacral  kyphosis,  front  and  profile  views  (author's  case). 


measurement  posteriorly  depends  also  upon  the  narrowness  of 
the  sacrum.  To  compensate  for  the  movement  of  the  upper 
portion  of  the  sacrum  backward,  the  lower  portion  of  the  bone 
projects  forward,  into  the  pelvic  outlet.  To  preserve  the 
body  from  falling  forward,  the  legs  are  slightly  flexed  and 
the  pelvic  inclination  is  almost  entirely  lost.      This  posture  puts 


514 


THE  PATHOLOGY  OF  LABOR. 


the  iliofemoral  ligaments  on  a  stretch,  which  pull  outward  the 
upper  portions  of  the  innominate  bones.  To  compensate  for 
the  movement  outward  of  the  iliac  bones  the  lower  segments  of 
the  innominate  bones  move  inward  upon  the  pelvic  outlet;  in 
other  v/ords,  there  is  a  rotation  of  the  innominate  bones  upon 
their  anteroposterior  axes.  The  result  of  these  movements  in 
the  pelvic  bones  is  to  enlarge  the  pelvic  inlet  in  its  anteroposterior 
diameter,  and  to  contract  the  canal  toward  the  outlet,  where  the 
diminution  of  the  diameters  is  most  marked 
in  the   transverse  (Fig.  388). 

In  the  cases  of  lumbosacral  kyphosis 
the  upper  portion  of  the  sacral  bone  may  be 
involved  in  the  necrotic  process  and  the 
sacrum  may  exhibit  deformities  by  destruc- 
tion of  its  tissues  (Fig.  394)  The  other 
characteristic  deformities  of  the  kyphotic 
pelvis  are  most  marked  in  this  type,  unless, 
as  in  one  instance,  the  body  is  bent  almost 
double,  and  it  is  necessary  to  rest  the  anterior 
portion  upon  an  artificial  support,  as  a  cane. 
In  this  case  the  pelvis,  although  relieved  of 
the  weight  of  the  trunk,  is  obstructed  by 
the  overhanging  lumbar  vertebrae  to  such  a 
degree,  perhaps,  that  the  inlet  is  practically 
obliterated  (pelvis  obtecta).  In  all  cases  of 
exaggerated  lumbosacral  kyphosis  the  pro- 
jecting lumbar  spine  blocks  the  pelvic  inlet 
and  seriously  obstructs  labor.  The  conju- 
gate diameter  must  be  measured  to  the 
lumbar  or  even  to  the  dorsal  vertebrae,  and 
is  exceedingly  short.  In  2 1  labors  compli- 
cated by  this  deformity  of  the  pelvis,  66  per 
cent,  of  the  mothers  and  75  per  cent,  of  the 
children  were  lost  (Winckel). 

Influence  on  Labor. — The  influence  of 
the  kyphotic  pelvis  upon  labor  is  usually 
not  felt  until  the  presenting  part  has  de- 
scended to  the  pelvic  floor.  In  consequence  of  the  shortened 
perpendicular  diameter  of  the  abdominal  cavity  there  is  always 
a  tendency  to  a  transverse  position  of  the  fetus  /;/  ntero,  but 
this  position  is  ordinarily  corrected  by  the  first  few  labor-pains. 
The  head  presents  in  95  per  cent,  of  cases,  the  breech  in  2  per  cent., 
according  to   the   statistics   collected   by  Klein,  ^    embracing  172 


Fig.  391. — Lum- 
bosacral kyphosis 
(rear). 


1  "Archivf.  Gyn.,"  Ed.  1,  H.  I. 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


515 


births  in  95  women.  When  the  head  arrives  at  the  pelvic  floor,  if 
the  occiput  is  directed  backward,  as  it  is  in  a  third  of  the  cases, 
anterior  rotation  will  very  likely  be  prevented  and  there  will  be  a 


Fetal  head 
Spine 

of  ischiu7n -/i/- 

Isckium 


Fig.  392- — Head  arrested  by  spines  of  ischia  in  a  kyphotic  pelvis  (Budin). 


Fig-  393- — Vertical  section  of  kyphotic  pelvis,  showing  the  head  arrested  by  the 
spines  of  the  ischia  (Budin). 


persistent  posterior  position.  A  j^ostcrior  rotation  of  the  occiput 
orio^inally  directed  anteriorly  is  not  rare.  It  occurred  in  fi\'e  of 
Klein's   cases   and    in   one    of  the   author's.      If  the    occiput    is 


5  1 6  THE  PA THOLOGY  OF  LABOR. 

directed  anteriorly,  the  transverse  diameter  of  the  head  may  be 
caught  between  the  approximated  spines  or  tuberosities  of  the 
ischiatic  bones,  and  labor  be  brought  to  an  indefinite  standstill 
(Figs.  392,  393).  The  head  usually  enters  the  pelvis  obliquely  or 
transversely.  Rotation  only  occurs  as  the  head  emerges  from  the 
outlet.  F"ace  presentations  occur  in  a  large  proportion  of  cases 
— four  per  cent,  of  the  head  presentations. 

Management  of  Labor  in  Kyphotic  Pelves. — An  exact  meas- 
urement of  the  pelvis  is  essential  to  a  determination  of  the  proper 
means  of  delivery.  If  the  child  is  of  normal  size,  pregnancy 
may  be  allowed  to  go  to  term  in  pelves  measuring  8.5  cm.  and 
more  in  the  transverse  diameter  of  the  pelvic  outlet.  Any 
asymmetry  of  the  ischia  constitutes  a  serious  complication, 
necessitating  operative  interference  that  might  be  avoided  in  a 
symmetrical  pelvis  with  smaller  diameters.     Below  8.5  cm.  down 


Fig.  394.— Lumbosacral  kyphosis  (pelvis  obtecta). 

to  6  cm.  in  the  transverse  measurement  of  the  outlet,  labor 
should  be  induced  at  the  thirty-sixth  week.  With  a  measure- 
ment less  than  6  cm.  Cesarean  section  is  indicated  absolutely. 
If  the  woman  is  first  seen  in  labor  at  term,  the  head,  if  it  is 
presenting,  should  be  allowed  to  descend  to  the  pelvic  floor 
and  the  woman  should  be  encouraged  to  make  vigorous  ex- 
pulsive efforts.  If  the  occiput  shows  a  disposition  to  rotate 
posteriorly,  the  movement  should  not  be  interfered  with,  for 
the  greater  bulk  of  the  occipital  region  finds  more  room  poste- 
rior to  the  tuberosities  than  it  does  anteriorh-.  The  author  has 
seen  an  occipito-anterior  position  of  the  vertex,  in  a  kyphotic  pel- 
vis, remain  stationary  until  the  head  rotated  from  an  anterior  to 
a  posterior  position,  when  the  vertex  was  expelled  w^ithout  further 
difficult}\     With  a  transverse  diameter  of  8.5    cm.   spontaneous 


ANOMALIES  IN   THE   EORCES    OE  LABOR.  517 

delivery  may  be  possible,  though  it  may  be  necessary  to  use 
forceps.  Below  8.5  cm.  the  forceps  may  be  tried  cautiously,  but 
pubiotomy  is  likely  to  be  required.  In  no  other  form  of  con- 
tracted pelvis  is  this  operation  so  successful.  Klein  found,  by 
experiments  on  the  cadaver,  that  by  a  separation  of  the  symphy- 
sis to  6  cm.  in  a  kyphotic  pehds,  the  tuberosities  moved  4.5  cm. 
further  apart.  Pubiotomy,  therefore,  might  be  expected  to  be 
successful  in  a  transverse  diameter  of  6  cm.  or  even  a  trifle  less. 
If  the  child  is  dead  or  if  the  i^raver  obstetrical  operations  are  not 
admissible,  craniotomy  should  be  performed,  in  case  the  forceps 
fail.  In  employing  forceps  the  operator  must  remember  the  dangers 
of  rupture  of  the  symphysis  and  deep  tears  of  the  vaginal  walls  to 
which  kyphotic  subjects  are  particularly  liable.  Version  has 
given  the  worst  results  of  all  the  obstetrical  operations  in  kyphotic 
pelves.  It  is,  therefore,  as  a  rule,  contraindicated,  although  in 
one  of  the  author's  cases,  complicated  by  eclampsia,  it  proved  the 


VI 

Fig.  395. — Asymmetrical  contraction  of  the  outlet  from  kyphoscoliosis. 

best  way  to  extract  the  child.  Klein's  statistics  show  that  in  fift}- 
eight  to  sixty  per  cent,  of  cases  the  labor  must  be  terminated  by 
operative  interference. 

Diagnosis. — The  diagnosis  of  a  kyphotic  pelvis  presents  no 
difficulties.  The  hump-back  is  obvious,  and  the  history  is 
easily  obtained  that  the  spinal  deformity  developed  early  in  life. 
The  pelvic  measurements  diagnostic  of  this  deformity  show  an 
increased  separation  of  the  iliac  crests  and  the  anterior  spines,  an 
abnormally  long  conjugate  diameter  of  the  inlet,  a  diminished 
distance  between  the  posterior  superior  .spines,  an  approximation 
of  the  tuberosities  of  the  ischiatic  bones,  and  some  diminution  in 
the  anteroposterior  diameter  of  the  pelvic  outlet.  The  buttocks 
are  flat  and  pointed  below,  the  external  genitalia  are  displaced 
forward  and  upward,  and  the  upper  edge  of  the  symphysis  is 
above  the  upper  edge  of  the  pubic  hair.  Care  should  always  be 
exercised    to  detect  asymmetry  in    these   pelves,  to  discover  an 


5i8 


THE  PATHOLOGY  OF  LABOR. 


arrested  development  with  general  contraction  which  is  common, , 
and  to  diagnosticate  lateral  contraction  at  the  pelvic  inlet.  These 
complicating  deformities  constitute  often  insuperable  obstacles  in 
labor,  even  though  the  transverse  diameter  of  the  outlet  is  not 
excessively  contracted. 

Klein  gives  the  following  table,  showing  the  contrast  between 
kyphotic,  normal,  and  rachitic  pelves,  taking  a  typical  example 
of  each,  the  measurements  being  made  upon  the  dried  specimen  : 


Sp.  il.  ant.  sup., •. 

Cr.  il., 

Conj.  extern., 

Spin.  il.  post,  sup., 

Height  of  anterior  surface  of  sacrum, 
Height  of  posterior  surface  of  sacrum, 

Diagonal  conjugate, 

True  conjugate, 

Transverse  diameter  of  pelvic  inlet,    . 
Spines  of  the  ischia,  ...         .... 

Tuberosities  of  the  ischia, 


m 

> 

J 

J 

< 

<  tn 

in  en 

ft- 
< 

■if 

0  ? 

2  0  ■ 

m  X 
0  a, 

0- 

§t4 

;? 

J 

^U 

J 

22.3 

28.1 

25 

21.7 

26.8 

28.7 

27-3 

25.2 

16.3 

18 

18.5 

15-5 

7-7 

5-7 

6.4 

3-5 

10.4 

14.2 

8.2 

8 

9-3 

9-4 

7.2 

6.2 

12.5 

19-3 

I3.b 

14-5 

1    10.9 

17.7 

13.2 

13.6 

12.9 

14-5 

II. 8 

II. 2 

10.2 

9-5 

6.6 

5-9 

II. 4 

10. 1 

4.6 

4-5 

27.25 

27-75 
14-5 


8.7 

7.6 

14.2 

13-5 
13.2 


Prognosis. — The  outlook  for  the  mother  and  child  depends 
upon  the  degree  of  the  deformity  and  upon  the  management  of 
the  labor.  In  the  minor  grades  of  contraction  in  the  cases 
collected  by  Klein,  the  maternal  mortality  was  6.6  per  cent.  In 
the  graver  cases  it  was  16  per  cent.  Neugebauer  puts  the 
maternal  mortality  at  24.3  per  cent.  The  mortality  of  the  in- 
fants has  varied  in  the  different  statistical  tables  from  36  to  49 
per  cent. 

Freqiiency. — The  kyphotic  pelvis  is  said  to  be  somewhat 
infrequent,  but  the  practitioner  in  active  practice  will  surely 
encounter  several  examples  in  the  course  of  his  career.  The 
writer  has  had  under  his  care  eight  well-marked  cases  of  kyphotic 
pelvis,  in  two  of  which  Cesarean  section  was  necessary.  In  three 
delivery  was  spontaneous.  One  required  forceps,  another, 
version.  Klein  found,  in  42,113  labors,  only  7  women  with 
kyphosis — a  proportion  of  i  :  6016. 

Scoliosis. — In  the  scoliotic  pelvis  there  is  some  degree  of 
oblique  contraction.  The  innominate  bone,  toward  which  the 
lumbar  vertebrae  are  bent,  receiving  the  greater  part  of  the  weight 
of  the  trunk,  is  pushed  upward,  inward,  and  backward  by  the 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


519 


extra  pressure  exerted  upon  it  b\'  the  liead  of  the  femur.  The 
acetabulum  on  this  side  is  displaced  anteriorly  and  upward  ;  the 
symphysis  is  pushed  over  to  the  opposite  side.  The  degree  of 
asymmetry  is  rarely  sufficient  to  constitute  an  obstruction  in 
labor.  The  scoliotic  pelvis  is,  however,  most  often  rachitic,  and 
in  addition  to  the  asymmetry  of  scoliosis  there  may  be  the  con- 
traction of  a  rachitic  pelvis  (Figs.  396,  397). 

Kyphoscoliosis. — In  a  combination  of  kyphosis  and  scoliosis 
of  the  spinal  column  the  pelvis  shows,  perhaps,  the  combined 


Fig.  396. — Scoliosis.  Rachitic 
pelvis:  C.  v.,  8.25  cm.  Craniotomy 
on  a  dead  child  (author's  case). 


Fig.  397. — Scoliotic  rachitic  pelvis. 


features  of  both,  but  the  kyphosis,  being  of  rachitic,  not  of 
carious,  origin,  is  not  angular,  and  is  situated  high  in  the 
dorsal  region,  where  it  may  be  compensated  for  entirely  by 
lumbar  lordosis  (Figs.  398,  399).  The  kyphoscoliotic  pelvis 
is  usually  an  asymmetrically  contracted  rachitic  pelvis  (PI.  ii, 
Fig.  i). 

Lordosis. — Primary  lordosis  not  the  result  of  pelvic  deform- 
ity or  of  spinal  disease  is  very  rare.  Aside  from  some  illustra- 
tions of  it  in  an  article  by  Neugcbauer  {loc.  cit.),  the  writer 
knows   of  no   reference  to  the  subject  except   his  own  (PI.  11, 


520 


THE  PATHOLOGY  OF  LABOR. 


Fig.  39^. — Kyphoscoliosis  (Leopold). 


ANOMALIES  IN  THE  FORCES  OF  LABOR.  $21 

Fig.  2).i  It  may  readily  be  seen  what  an  influence  this  deformity 
would  have  upon  coition  and  parturition,  and  how  it  might  be  an 
insuperable  obstacle  to  the  natural  completion  of  the  latter. 


Fig.   2ijg. — Kyphoscoliosis.      Pelvis  of  rachitic   type:   C.   v.,  S.50  cm.  (seen  in  con- 
sultation with  Dr.  Geo.  I.  McKelway). 


Anomalies   Due  to   Diseases  of  the   Subjacent  Skeleton. — 

Coxalgia, — The  deformity  of  the  pelvis  due  to  coxalgia  in  early 
childhood  is  of  two  types.  In  one  there  is  an  oblique  contraction 
by  a  displacement  of  the  innominate  bone  on  the  healthy  side  up- 

^  Hirst,  "  The  Iiiiluence  of  the  IIai)itiial  Inclination  of  tlic  Pelvis  in  the  J'>cct 
Posture  upon  the  Shape  and  Size  of  the  Pelvic  Canal,"  "  University  Med.  Maga- 
zine." 


522 


THE   PATHOLOGY  OF  LABOR. 


ward,  backward,  and  inward,  on  account  of  the  pressure  of  the 
femur,  the  weight  of  the  body  being  received  mainly  upon  the 
sound  leg.  This  form  of  coxalgic  pelvis,  as  a  rule,  presents  no 
serious  obstacle  to  delivery  unless  it  is  associated  with  a  rachitic 
deformity  (Fig.  400).  Special  attention,  however,  should  always 
be  paid  to  the  length  of  the  conjugate  diameter  of  the  inlet, 
and  to  the  transverse  diameter  of  the  outlet.  In  the  other 
variety  of  coxalgic  pelvis  the  deformity  is  also  an  oblique  con- 
traction, but  it  is  the  bone  on  the  diseased  side  which  is  driven 
inward  upon  the  pelvic  canal.  This  displacement  of  the  innomi- 
nate bone  is  the  result  of  an  arrested  development  on  the  corre- 
sponding side  of  the  pelvis,  and  is  usually  associated  with  an 
atrophy  of  the  sacral  ala  and  an  ankylosis  of  the  sacro-iliac  joint. 
The  contraction  of  the  pelvic  canal  is  much  more  serious  in  this 


Fig.  400. ^Coxalgic  pelvis  (Mutter  Museum,  College  of  Physicians,  Philadelphia). 


form,  and  there  may  be  all  the  difficulties  in  labor  encountered 
in  the  true  Naegele  pelvis. 

The  ankylosis  of  the  hip-joint  and  the  fixation  of  the  thigh 
in  coxalgia  may  be  a  source  of  serious  embarrassment  in  labor, 
especially  in  the  application  of  forceps  and  the  extraction  of  the 
fetal  head  through  the  pelvic  outlet. 

Luxation  of  the  Femora. — Dislocation  of  the  thigh-bones,  if 
congenital  or  occurring  early  in  childhood  and  not  corrected, 
has  some  effect  upon  the  size  and  shape  of  the  pelvis,  but  usually 
not  enough  seriously  to  obstruct  labor.  If  one  thigh  is  dislo- 
cated, the  weight  of  the  body  may  be  thrown  mainh'  upon  the 
other  leg,  and  this  may  produce  an  oblique  contraction  of  the 
pelvis  of  the  kind  already  described.  If  the  thigh-bone  is 
displaced  forward,  the  anterior  half  of  the  pelvis  may  be 
driven  in  a  little  upon  the  pelvic  canal,  and  the  head  of  the  thigh- 
bone, as  in  one  case   reported,  may  project   over  the   horizontal 


ANOMALIES  IN  THE   FORCES   OF  LABOR. 


523 


Fig.  401. — Anterior  dislocation  of  femur. 


Fig.  402. — Congential  luxation  of 
both  femora :  C,  Crest  of  ilium ;  F, 
trochanter  of  femur  (Henry). 


Fig.  403. — Congenital  dislocation 
of  femora,  rear  view,  showing  wide 
separation  of  the  thighs  with  the  feel 
together  (author's  case). 


524  THE  PATHOLOGY  OF  LABOR. 

ramus  of  the  pubis  into  the  pelvic  inlet  (Fig.  401).  In  the  con- 
genital luxation  of  both  femora  backward  upon  the  iliac  bones 
there  is  an  excessive  rotation  forward  of  the  sacrum,  an  increased 
width  of  the  pelvic  canal,  and  from  the  drag  of  the  attached 
muscles  and  ligaments  between  the  thighs  and  the  pelvis  the 
ischiatic  tuberosities  are  pulled  outward,  upward,  and  backward, 
so  that  the  pelvic  canal  is  made  shallow  and  its  outlet  N&ry  wide. 
The  heads  of  the  femora  move  up  and  down  on  the  ilia  when  the 
patient  walks,  and  the  distance  between  the  lower  edge  of  the 
symphysis  and  the  inner  condyles  of  the  femora  is  shortened. 

There  is  a  peculiar  waddling  gait,  a  marked  lordosis,  and 
the  shoulders  arc  carried  far  back.  The  rear  view  of  the  patient 
shows  an  unusually  wide  separation  of  the  thighs  as  the  individual 
stands  erect  with  the  heels  together. 

In  the  absence  of  one  lower  extremity  the  pelvis  may  be 
contracted  obliquely  to  a  serious  degree,  as  in  La  Chapelle's 
case,  ^  by  the  pressure  on  one  side  of  the  remaining  leg.  Any 
condition  which  throws  the  weight  of  the  body  mainly  on  one  leg 


Fig.  404. — Congenital  luxation  of  both  femora. 

may  produce  the  same  effect,  as  is  shown  in  a  case  of  the  author's 
(PI.  II,  Figs,  4,  5),  in  which  there  was  tuberculous  disease  of  a 
knee-joint  early  in  infancy,  followed  by  marked  shortening  and 
atrophy  of  the  leg.  The  weight  of  the  body  falling  mainly  on 
the  sound  leg,  the  corresponding  innominate  bone  is  pushed 
upward,  backward,  and  inward,  diminishing  the  area  of  in- 
trapelvic  space  on  its  own  side.  Torggler  reports  an  inter- 
esting case  of  this  kind  in  which  the  disability  of  one  leg 
was  due  to  scleroderma.^  In  the  absence  of  both  lower  ex- 
tremities there  is  the  characteristic  "  sitz-pelvis,"  in  which  the 
innominate  bones  are  usually  rotated  on  an  anteroposterior  axis, 

1  "  Pratique  des  Accouchements,"  ill,   p.   413;  according   to   Schauta,  the  only 
case  on  record.  2  "  Centralbl.  f.  Gyn.,"  1889,  p.  612. 


ANOMALIES  IN   THE  FORCES   OF  LABOR.  525 

SO  that  the  crests  of  the  iHa  are  approximated  and  the  tuberosi- 
ties of  the  ischia  are  separated.  Minor  deformities  of  little  prac- 
tical importance  may  be  the  result  of  unilateral  or  bilateral  club- 
foot or  of  the  bowing  of  one  or  both  lower  extremities.  In  the 
former  there  is  an  increased  inclination  of  the  pelvis,  an  approxi- 
mation of  the  acetabula  and  of  the  ischiatic  tuberosities,  and  a 
narrow  pubic  arch  (Fig.  405). 


Fig.  405. — Pelvic  deformity,  the  result  of  double  club-foot  (Meyer). 

The  Management  of  Labor  Obstructed  by  the  Commonest 
Forms  of  Contracted  Pelvis  :  a  Simple  Flat,  a  Rachitic  Flat, 
and  a  Generally  Contracted  Pelvis. — There  is  nothing  in 
medicine  requiring  more  experience  and  good  judgment  than  the 
management  of  labor  obstructed  by  a  contracted  pelvis.  It  is 
extremely  difficult  to  formulate  hard-and-fast  rules  for  the  guid- 
ance of  the  inexperienced  when  so  many  factors  must  be  taken 
into  account.  The  rules  given  below  govern  the  writer's  prac- 
tice in  the  average  case,  but  due  attention  must  be  paid  to  the 
history  of  past  labors,  the  size  of  the  child,  its  development, 
and  the  compressibility  of  its  head,  the  age  of  the  woman, 
the  build  of  both  parents,  and  the  probable  strength  of  the  ex- 
pulsive forces,  greatest  in  the  primipara  and  less  with  successix'c 
labors. 

If  the  diagnosis  of  a  conjugate  diameter  of  9.5  cm.  or  less 
is  made  during  pregnancy,  the  physician  must  choose  induction 
of  premature  labor,  forceps,  version,  pubiotomy,  or  Cesarean 
section  at  term.  If  the  conjugate  diameter  measures  as  low  as 
9.5  cm.,  it  is  a  safe  plan  to  induce  labor  two  to  four  weeks  before 
the  expected  termination  of  pregnancy.  This  course  entails 
no  great  additional  risk  upon  the  chikl  if  its  parents  are  in  a 
position  to  afford  it  the  best  care  and  nursing,  and  it  is  much 
the  safest  plan  for  the  mother,  the  induction  of  labor,  done  prop- 


526  THE   PATHOLOGY  OF  LABOR. 

erly,  having  no  maternal  mortality.  ^  It  is  true  that  many  women 
with  a  conjugate  of  9.5  cm.  can  deliver  themselves  without 
difficulty  at  term.  Spontaneous  delivery  with  a  measurement 
as  low  as  eight  centimeters  and  under  has  been  recorded:  But 
the  majority  of  women  with  a  conjugate  of  9.5  cm.  will  ex- 
perience abnormal  delay  and  difficulty  in  labor,  with  added  risk 
to  themselves  and  to  their  children  ;  and  in  a  certain  propor- 
tion of  cases  a  conjugate  of  9.5  cm.  proves  an  insuperable 
obstruction  in  labor,  and  is  the  cause  of  ruptured  uterus  or  death 
from  exhaustion  in  the  mother  or  of  injury  to  the  child's  brain. 
These  results  are  to  be  feared  especially  if  the  child  is  over- 
grown or  if  the  mother's  expulsive  powers  are  weak — two  con- 
ditions impossible  to  predict  with  absolute  certainty.  For  these 
reasons,  then,  the  rule  to  induce  premature  labor  when  the  con- 
jugate is  at  or  below  9.5  cm.  is  a  safe  one.  If  the  conjugate 
measures  eight  centimeters  or  more,  the  most  successful  treatment 
is  still  the  induction  of  premature  labor  at  the  thirty-sixth  week. 
By  this  plan  the  majority  of  women  with  a  conjugate  of  eight  centi- 
meters or  a  trifle  less  are  delivered  spontaneously  or  with  no  more 
serious  operation  than  the  application  of  forceps.  If  the  conjugate 
measures  seven  centimeters  or  less,  the  induction  of  premature  labor 
four  Weeks  before  term  cannot  be  expected  of  itself  to  secure  a 
spontaneous  delivery.  Cesarean  section  gives  a  better  result  for 
both  mother  and  child.  In  such  cases,  therefore,  the  physician 
may  wait  until  term  or  shortly  before  it,  so  that  his  operation  shall 
secure  the  birth  of  a  child  vigorous  in  development.  With  a  con- 
jugate diameter  of  the  superior  strait  at  and  below  7  cm.,  the  woman 
should  be  allowed  to  go  to  term  and  should  usually  be  delivered 
by  Cesarean  section. 

If  the  physician  sees  the  patient  for  the  first  time  in  labor,  or 
only  discovers  the  deformity  after  labor  has  begun,  he  must 
choose  one  of  the  following  modes  of  delivery:  A  waiting  policy, 
to  allow  the  engagement  of  the  head  by  natural  forces;  the  ap- 
plication of  forceps;  the  performance  of  version,  pubiotomy, 
or  Cesarean  section.  While  the  child  is  alive,  craniotomy 
should  not  be  considered.  The  selection  of  the  best  mode  of 
delivery  in  contracted  pelves  is  one  of  the  most  diflicult  problems 
in  obstetrics.  If  the  patient  is  primapara  and  the  conjugate  is 
above  nine  centimeters,  natural  forces,  in  the  majority  of  cases, 
if  the  fetus  is  not  overgrown,  will  secure  the  engagement  of  the 

^  This  statement  is  based  upon  the  writer's  experience  in  private  practice,  and 
not  upon  hospital  statistics.  It  does  not  hold  good  for  labors  induced  before  the 
thirty-sixth  week.  In  the  discussion  at  the  international  congress  at  Amsterdam,  in 
August,  1899,  the  maternal  mortality  was  acknowledged  to  be  about  i  per  cent.,  and 
for  the  infants  Barnes  gave  a  mortality  of  t^^i  F^^'  cent..  Bar  26  per  cent.,  Becker  50 
per  cent.,  Hcrzman  26  per  cent.,  and  Black  50  per  cent.  These  figures,  however, 
are  preposterously  incorrect  for  private  practice. 


ANOMALIES  IN   THE  FORCES    OF  LABOR.  527 

head/  although  it  may  be  by  the  expenditure  of  considerable 
force,  after  long  delay,  and  only  after  prolonged  molding  and  an 
adaptation  of  the  size  of  the  head  to  the  size  of  the  contracted  inlet 
by  apparent  anomalies  in  the  position  and  flexion  of  the  former. 
It  is  wonderful  how  successfully  an  obstruction  may  be  overcome 
even  in  cases  of  contracted  pelves  with  a  conjugate  of  eight  centi- 
meters or  less.  But  while  waiting  for  spontaneous  delivery,  the 
physician  may  see  the  uterus  suddenly  rupture  or  may  find  the 
child's  head  after  birth  seriously  injured.  It  is  permissible  in 
most  cases  to  Avait  for  the  full,  or  almost  full,  dilatation  of  the 
OS,  keeping  careful  watch  upon  the  woman's  pulse,  temperature, 
and  general  condition,  upon  the  situation  of  the  contraction-ring 
and  the  distention  of  the  lower  uterine  segment,  and  taking 
whatever  operative  measures  may  be  required  in  plenty  of  time 
to  forestall  the  possibility  of  uterine  rupture.  The  application 
of  forceps  to  the  head  above  the  superior  strait  for  the  purpose 
of  securing  its  engagement  by  forcible  traction  should  in  general 
be  condemned,  but  it  must  be  admitted  that  there  are  important 
exceptions  to  this  rule.  If  one  is  skilled  in  the  application  of  the 
forceps,  bears  in  mind  the  transverse  position  of  the  head,  and 
can  gage  the  degree  of  traction  which  may  be  exerted  without 
injury  to  the  child's  skull  or  to  the  maternal  soft  structures,  he 
will  occasionally  succeed  in  securing  an  engagement  with  the  in- 
strument that  would  otherwise,  perhaps,  be  impossible.  As  a 
rule,  however,  it  is  safe  to  say  that  the  choice  lies  between  in- 
action and  the  performance  of  version.  By  the  latter  operation 
the  smaller  end  of  the  wedge  represented  by  the  child's  head  is 
engaged  in  the  contracted  inlet,  and  there  can  be  exerted  upon 
the  head  coming  last,  both  by  traction  on  the  body  from  below 
and  by  pressure  on  the  head  through  the  abdominal  walls  above, 
a  degree  of  force  that  is  impossible  with  forceps.  It  is  well, 
however,  to  bear  in  mind  the  danger  entailed  upon  fetal  life 
when  version  is  performed  in  a  contracted  pelvis.  There  is  a  con- 
siderable risk 2  that  the  head  will  be  retained  long  enough  above 
the  superior  strait,  or  in  it,  to  asphyxiate  the  child  beyond  re- 
vival. ^      Or  the  pressure  upon  the  head  by  the  pelvic  walls  may 

1  From  1881  to  1887  there  was  spontaneous  delivery  in  163  out  of  444  cases  of  con- 
tracted pelvis  in  the  Vienna  Hospital,  and  in  47  women  the  conjugate  was  not  above 
8.5  centimeters  (Braun  u.  Herzfeld,  "  Der  Kaiserschnitt  u.  seine  Stellung  zur  kiinst- 
lichen  I'Vlihgeburt,  Wendung,  atypischen  Zangenoperationen,  Kraniotomie  bei  u.  zu 
den  spontanen  Geburten,"  Wien,  1888,  ii,  p.  144).  In  the  Moscow  Maternity  there 
were  84  contracted  pelves  among  4000  births  in  1894;  71  percent,  of  these  cases 
were  spontaneously  delivered  (Kiister,  "  Centralblatt  f.  Ciyn.,"  No.  10,  1895). 

2  The  infantile  death-rate  will  be  at  least  twenty-five  per  cent.,  or  more  likely 
higher  (Nagel,  "  Die  Wendung  bei  engen  I'ecken,"  "  Archiv  f.  Gyn.."  Bd.  xxxiv). 

'^  Nagel  reports  sixty  cases  of  version  for  contracted  pelvis,  with  a  fetal  mor- 
tality of  twenty-five  per  cent,  [ibid.,  p.  168). 


528  THE  PATHOLOGY  OF  LABOR. 

fracture  the  skull  and  crush  the  brain,  and  the  force  employed  in 
extraction  may  break  the  neck.  If  in  the  judgment  of  the  oper- 
ator the  danger  entailed  upon  the  fetus  by  version  is  too  great, 
natural  forces  having  failed  to  secure  engagement,  and  if  he  has 
tried  the  forceps  cautiously  without  success,  his  choice  must  rest 
between  pubiotomy  and  Cesarean  section.  The  former  will 
be  selected  only  in  isolated  instances  with  most  favorable  con- 
ditions if  the  conjugate  is  above  seven  centimeters;  the  latter, 
always  in  cases  of  greater  contraction  than  seven  centimeters,  and 
occasionally  as  a  relative  indication  with  a  conjugate  as  large  as 
8.5    cm.       These   rules   for   the   treatment    of   labor   obstructed 


\    '       -       "  ~  '  /  tf' 


Fig.  406. — Walcher  posture  :   the  conjugate  of  the  brim  is  a  black  line,  and  the 
amount  of  space  gained  is  a  dotted  continuation  of  this  line. 


by  a  contracted  pelvis  presuppose,  of  course,  a  fetal  body  and 
head  of  average  size.  This  point  must  always  be  investigated 
carefully  by  abdominal  palpation  or  by  mensuration  of  the  fetal 
head,  although  it  is  difficult  to  determine.^  If  the  physician  has 
reason  to  believe  that  the  child  is  oversized,  he  must  allow  himself 
sufficient  latitude  to  insure  delivery.     If  the  child  is  undersized 

1  The  relative  size  of  head  and  pelvis  may  be  determined  approximately  by  the 
method  of  Midler  and  Schatz.  The  fetal  head  is  grasped  between  the  extended 
fingers  of  the  physician,  and  is  pressed  down  steadily  and  for  some  time  upon  the 
pelvic  brim,  the  direction  of  the  force  coinciding  with  the  axis  of  the  superior  strait. 
If  this  manoeuver  succeeds  in  pressing  the  head  within  the  pelvis,  then  natural  forces 
■will  surely  secure  engagement.  If  it  fails,  tiie  converse  by  no  means  necessarily 
follows.      Other  methods  of  antepartum  fetometry  are  described  on  page  465. 


ANOMALIES  IN   THE   FORCES   OF  LABOR. 


529 


(a  condition  easier  to  detect  by  palpation  than  overgrowth), 
spontaneous  dehvery  may  be  expected  through  a  pelvis  that  would 
not  permit  the  passage  of  a  child  of  normal  size.  Klein  and  Wal- 
cher  declare  that  by  raising  the  buttocks  and  letting  the  limbs 
hang  down  as  much  as  possible  the  conjugate  diameter  is  length- 
ened by  almost  a  centimeter.  Clinical  tests  of  the  method  are 
described,  attended  with  success/  The  Walcher  posture  has 
been  indorsed  by  a  number  of  observers  in   Germany  and   in 


Fig.  407. — ^Tlie  Walcher  posture. 

other  countries.  The  author  has  found  it  of  decided  advantage, 
and  recommends  its  systematic  trial. 

There  is  a  growing  disposition  to  enlarge  the  indications  for 
Cesarean  section  as  against  high  forceps  and  version  in  moderately 
contracted  pelves.  I  am  in  sympathy  with  this  movement,  but  only 
if  the  operator  is  a  well-trained  abdominal  surgeon  with  sufficient 
obstetric  experience  to  judge  correctly  the  difi&culties  to  be  an- 
ticipated in  a  vaginal  delivery. 

An  exceedingly  puzzling  problem  is  presented  by  cases  brought 


1  "  Zeitschrift  f.  Geburts.  u.  Gyn.,"  Bd.  xxi,  H.  i,  and  "Med.  Korresp.  Bl. 
des  Wiirtemb.  Aerztl.  V.,"  Bd.  Ix,  5.  Lebedeff  and  Bartosziurcz,  by  experiments 
on  25  cadavers,  found  that  the  Walcher  position  lengthened  the  conjugate  of  the  inlet 
from  I-3  mm.,  "International  Congress  for  Gyn.  and  Obstet.,"  Amsterdam. 
Pinzani  in  62  observations  found  an  increase  of  1—8  mm.,  ibid. 

34 


530  THE   PATHOLOGY  OF  LABOR. 

to  a  specialist  after  hours  of  obstructed  labor  and  many  internal 
examinations  or  manipulations  with  faulty  asepsis.  Cesarean 
section  has  a  higher  mortality  in  such  cases,  not  on  account  of  the 
length  of  labor,  but  because  of  an  infected  birth-canal.  Frank 
advocates  a  suprasymphyseal  incision  and  extraperitoneal  de- 
livery in  these  cases,  reviving  the  idea  of  Joerg  and  Ritgen,  but 
American  surgeons,  who  remember  the  experience  of  Thomas  and 
others  with  "laparo-elytrotomy, "  will  be  loath  to  accept  this 
advice.  The  advocates  of  pubiotomy  claim  that  under  these  cir- 
cumstances it  is  a  safer  operation  than  Cesarean  section,  and 
this  claim  is  in  a  m.easure  correct,  but  with  an  infected  birth- 
canal  the  difference  in  mortality  between  the  two  is  not  very  strik- 
ing. Personally  I  am  in  favor  of  Ceserean  section  in  these  cases, 
but  with  an  extremely  painstaking  disinfection  of  the  birth-canal 
and  the  technic  of  the  operation  carried  out  as  described  on  p.  857. 
As  an  example  of  what  can  be  accomplished  in  this  way :  A  woman 
was  brought  to  the  University  Hospital  with  the  baby's  arm  pro- 
truding from  the  vulva.  The  head  and  shoulder  were  locked  in 
a  uterus  condiformis,  with  the  mem.branes  long  ruptured.  The 
patient  had  been  under  the  charge  of  an  ignorant  midwife  and 
came  from  a  filthy  hovel.  The  vulva  was  cleansed,  the  arm  dis- 
infected and  returned  to  the  uterine  cavity;  the  vagina  disinfected 
and  packed.  A  conservative  Cesarean  section  proved  entirely  suc- 
cessful for  both  mother  and  child.  The  woman  made  an  afebrile 
convalescence.  As  a  rule,  however,  the  Porro  operation  would 
be  more  suitable  in  such  a  case. 

Obstruction  to  Labor  on  the  Part  of  the  Soft  Maternal 
Structures  in  the  Parturient  Canal. — Congenital  Anomalies  of 
Development  in  the  Uterus. — A  double  or  septate  uterus  may  com- 
plicate labor  in  several  ways.  The  bulk  of  the  unimpregnated 
half  may  obstruct  delivery,  especially  if  this  half  is  retroverted 
and  is  increased  considerably  in  size  in  sympathy  with  the  de- 
velopment of  the  impregnated  side,  and  is  hardened  in  consist- 
ency by  sympathetic  contraction  during  the  labor-pains.  The 
septum  itself  may  prove  an  obstacle  in  labor,  a/ud  sometimes 
labor  is  obstructed  by  the  strong  vesicorectal  ligament  that  runs 
between  the  horns  of  a  bicornate  uterus.  If  the  placenta  is  at- 
tached to  the  septum,  alarming  hemorrhage  may  occur  from  im- 
perfect contraction  of  the  sparsely  supplied  muscular  fibers  in  it. 
Malpresentations  of  the  fetus  and  a  faulty  direction  and  insufifi- 
cient  power  of  the  expulsive  force  are  common.  Rupture  of  the 
uterus  is  to  be  feared  on  account  of  the  ill-developed  uterine  walls. 
Laceration  of  the  septum  frequently  occurs.  It  has  been  noted  that 
a  decidual  membrane  may  be  retained  within  the  non-pregnant  half 


ANOMALIES  IN   THE   FORCES   OF  LABOR.  53I 

of  the  uterus,  where,  undergoing  putrefaction  after  deHvery,  it  may- 
give  rise  to  septic  infection.  There  seems  also  to  be  a  disposition 
to  the  retention  of  membranes  in  the  pregnant  side  of  the  womb. 
Retention  of  the  placenta  is  not  uncommon,  partly  because  of 
insufficient  expulsive  force,  partly  on  account  of  its  situation, — 
perhaps  attached  in  both  divisions  of  the  uterine  cavity.  The- 
vard^  reports  the  retention  of  the  placenta  in  a  double  uterus  for 
fifty  days,  when  it  was  spontaneously  discharged.  It  has  hap- 
pened, in  cases  of  double  uterus  and  vagina,  that  the  physician  ex- 
amined the  wrong  side,  and  was  ignorant  of  the  progress  of  labor 
until  the  child  was  about  to  be  born  ;  also  that  he  examined 
first  one  side  and  then  the  other,  finding  first  a  dilated  and  then 
a  contracted  external  os. 

In  one  woman  with  a  double  uterus  there  was  noted  a  dis- 
position to  become  pregnant  in  regular  alternation  first  on  one 
side  and  then  upon  the  other."  It  is  said  that  ovulation  in 
these  cases  occurs  in  one  ovary  one  month;  in  the  other,  the 
next.^ 

Closure  and  Contraction  of  the  Cervix. — The  cervix  may  ob- 
struct labor  by  reason  of  atresia,  cicatricial  infiltration,  contrac- 
tion, and  rigidity,  or  there  may  be  longitudinal  or  transverse 
septa  in  the  canal.  Atresia  of  the  cervix  in  a  pregnant  woman 
is  acquired  after  impregnation  {conglutinatio  orificii  uteri  externi) ; 
it  is  rarely,  however,  complete.  There  is  always  an  indication 
at  least  of  the  external  os  in  a  dimple  evident  to  the  sense  of  sight 
if  not  to  that  of  touch.  By  pressing  upon  this  point  with  a  finger- 
nail or  with  the  tip  of  a  uterine  sound,  a  small  artificial  opening 
may  be  made.  Directly  this  is  secured,  the  dilatation  of  the  ex- 
ternal OS  proceeds  in  a  remarkably  rapid  manner,  although  hours 
of  vigorous  labor-pains  before  had  been  insufficient  to  begin  it. 
If  this  plan  fails,  a  crucial  incision  must  be  made  in  the  cervical 
tissues  at  the  site  of  the  external  os.  The  dilatation  of  the  small 
opening  thus  made  is  then  left  to  nature.  If  hemorrhage  follows 
the  incisions,  the  bleeding  points  should  be  secured  by  sutures  after 
the  conclusion  of  labor.  An  active  treatment  is  always  called  for. 
Without  it  the  uterus  may  rupture,  the  vaginal  portion  of  the  cervix 
may  be  torn  off  from  the  womb,  or  the  head  may  emerge  completely 
covered  by  the  enormously  distended  cervix  as  by  a  caul.^  Cicatri- 
cial contraction  or  infiltration  of  the  cervix  is  the  result  of  old,  unre- 

'  "  Nouvelles  Archives  d'Obst^tritjue  et  de  Gynecologie,"  1S90,  p.  640. 
^  Southermann,  ■' Berliner  med.  Woclien.,"  1879,  41. 

^Guerin-Vaimale,  "  De  I'evolution  de  la  puerperalitii  dans  I'utenis  didelphe,"' 
"  L'Obstetrique,"  May,  1904. 

•*  Jeutzen,  "  iVrchives  de  Ti).\icologie,"  Paris,  1890,  M.  8. 


532  THE   PATHOLOGY  OF  LABOR. 

paired  tears,  of  operations  upon  tlie  cervix,  of  cauterization,  of 
syphilis,  or  of  cancer.  In  the  first  instance  the  resistance  to  dilata- 
tion is  scarcely  ever  great,  and  what  there  is  may  be  almost  always 
overcome  by  hydrostatic  dilators,  by  the  application  of  the  forceps 
and  forcible  delivery  of  the  head  through  the  cervical  canal,  or 
by  the  performance  of  version  followed  by  rapid  extraction.  If 
the  cicatrices  are  of  syphilitic  or  of  cancerous  origin,  the  obstruc- 
tion is  more  serious.  It  may  be  overcome  by  radiating  incisions 
with  scissors  or  with  a  probe-pointed  bistoury,  but  it  is  not  un- 
likely to  demand  the  performance  of  abdominal  or  vaginal  Cesa- 
rean section. 

Rigidity  of  the  cervix  is  seen  normally  in  all  primiparae,  and 
to  an  exaggerated  degree  in  elderly  primiparae.  It  yields  often 
to  copious  douches  of  warm  water  directed  against  the  anterior 
wall  of  the  cervix  and  frequently  repeated — as  often  as  once 
every  fifteen  minutes  if  necessary.  Chloral  internally  and  bella- 
donna ointment  applied  directly  to  the  cervix  have  been  recom- 
mended, but  these  remedies  are  not  to  be  depended  upon  except 
in  the  slight  rigidity  characteristic  of  all  primiparae.  If  there  is 
delay  in  such  cases,  fifteen  grains  of  chloral  every  fifteen  minutes 
for  three  doses  may  advantageously  be  given.  An  anesthetic, 
after  all,  is  the  most  valuable  medicinal  agent  that  we  possess  for 
the  relaxation  of  this  as  well  as  of  other  rigid  tissues.  The  rigid 
cervix  yields  at  length  to  the  steady  pressure  of  the  presenting  part, 
and  it  is  rarely  necessary  on  account  of  rigidity  alone  to  resort  to 
artificial  dilatation  or  to  incisions.  In  the  course  of  a  slow  dilata- 
tion of  the  cervical  canal  and  external  os  the  anterior  lip  may  be- 
come incarcerated  between  the  head  and  the  pelvic  walls.  In  con- 
sequence of  the  pressure  and  the  disturbance  of  circulation  in  the 
part  the  cervical  tissues  rapidly  become  edematous,  and  the  bulk 
of  the  anterior  lip  becomes  so  great  as  actually  to  constitute  a 
mechanical  obstruction  to  the  descent  of  the  head.  It  is  usually 
possible  in  such  cases  to  push  up  the  anterior  lip  over  the  head 
and  above  the  symphysis  in  the  intervals  between  the  pains.  If 
there  is  hypertrophy  of  the  anterior  lip  in  consequence  of  an  old 
laceration  and  eversion,  or,  all  the  more,  should  there  be  hyper- 
trophy of  the  whole  infravaginal  portion  of  the  cervix,  the  ob- 
struction may  become  quite  serious,  and  it  may  be  impossible  to 
push  the  cervix  above  the  head.  In  such  cases  forcible  traction  on 
the  forceps  or  radiating  incisions  in  the  cervix  may  be  necessary. 

Longitudinal  .septa  in  the  cervical  canal  are  usually  seen  with 
duplicity  of  the  uterine  cavity  from  failure  of  the  Miillerian  ducts 
to  fuse  completely.  Occasionally  the  lack  of  fusion  is  confined 
to  the  cervical  canal  alone  {uterus  biforis).      Rareh',  transverse 


ANOMALIES  IN   THE   FORCES    OF  LABOR. 


533 


septa  have  been  found  in  the  cervical  canal. ^     It  may  be  neces- 
sary to  cut  them  before  the  child  can  pass  into  the  vagina. 


Fig.  408. — Double  vagina. 


Closure  and  Contraction  of  the  Vagina  or  Vulva. — There  may  be 
obstruction  of  the  lower  birth-canal  by  longitudinal  and  trans- 
verse septa,  by  cicatrices,  by  hematomata,  by  partial  atresia, 
either  congenital  or  acquired,  by  unruptured  hymen,  by  anus 
vaginalis,  by  vaginal  tumors  and  cysts,  by  cystic  and  solid 
tumors  of  the  vulva,  by  enlarged  carunculae  myrtiformes,  by 
varices,  by  vaginismus,  by  congenital  narrowness  of  the  vagina 
and  vulva,  and  by  rigidity  of  the  tissues,  especially  in  elderly 
primipar^e. 

LongitiidbiaL  and  transverse  septa  are  not  ordinarily  \'cry 
dense  in  structure,  and  they  give  way  commonly  before  the 
advance  of  the  presenting  part.  If  they  do  not  yield,  it  is  easy 
to  cut  them  in  one  or  more  places,  the  hemorrhage  being  con- 
trolled, if  necessary,  by  sutures  afterward,  or,  in  the  case  of  trans- 
verse septa,  by  a  double   ligature  applied  first,  tlie  septum  being 

'Cases  are  reported  by  Miiller,  Breisky,  lindiii,  Ifrnr\-,  ISidiler,  and  Diane 
(Pozzi's  '*  Gynecology,"  vol.  ii,  p.  456). 


534 


THE   PATHOLOGY  OF  LABOR. 


cut  between,   though   there  is  not   much  tendency   to  bleeding 
even  in  those  as  thick  as  one's  finger  (Fig.  409). 


Fig.  409. — Transverse  septum  of  the 
vagina  (Heyder). 


Fig.  410. — Anus  vestibularis.  Dot- 
ted lines  show  the  limit  of  mucous 
membrane ;  thickened  skin  marks  the 
normal  site  of  the  anus  (Dickinson). 


Hematoniata. — Hematomata  of  the  parturient  tract  usually 
occur  at  the  vaginal  orifice,  and  most  often  between  the  birth  of 
twins.  They  are  considered  here  only  as  mechanical  obstacles 
to  labor.  If  the  blood-tumor  is  large  enough  to  constitute  an 
obstruction  to  the  escape  of  the  child,  its  walls  must  be  incised 
and  its  contents  be  turned  out,  and  if  hemorrhage  follows,  it  must 
be  checked  by  a  firm  tampon,  preferably  of  iodoform  gauze,  in 
the  cavity  of  the  tumor. 

Extensive  cicatrices  in  the  vagina  from  syphilitic,  malignant, 
or  other  ulceration,  or  from  former  injuries,  may  be  stretched 
sufficiently  by  hydrostatic  dilators  or  maybe  severed  by  multiple 
incisions,  followed  by  the  application  of  forceps  if  the  head  is 
presenting  ;  but  they  may  be  too  dense  and  extensive  to  yield 
to  these  measures,  and  a  Cesarean  section  may  be  required. 

Unruptured  Hymen. — An  unruptured  hymen  is  not  neces- 
sarily a  bar  to  conception.  There  are  a  number  of  cases  on 
record  in  which  a  persistent  hymen  with  a  small  orifice  has  ob- 
structed to  some  degree  the  escape  of  the  child's  head  in  labor. 
In  two  cases  under  the  author's  notice  the  advance  of  the  pre- 


ANOMALIES  IN  THE    FORCES    OF  LABOR.  535 

senting  part  ruptured  the  hymeneal  membrane  without  difficuhy, 
but  it  has  been  found  necessary  by  others  to  incise  it.  ^ 

Atresia  of  the  Vagina. — The  canal  may  be  obstructed  by  an 
annular  membrane  like  the  hymen.  Although  Cesarean  section 
has  been  done  for  this  condition,  it  is  not  required.  The  advance 
of  the  presenting  part  has  dilated  the  narrowed  vaginal  canal 
with  less  difficulty  than  it  experiences  in  dilating  the  cervical 
canal.  The  author  has  seen  three  cases.  At  the  worst,  the 
obstruction  should  be  overcome  by  digital,  instrumental,  or  hydro- 
static dilatation.  In  complete  or  almost  complete  acquired  atresia 
of  the  lower  portion  of  the  vagina,  in  which  insemination  has 
taken  place  by  way  of  a  dilated  urethra  and  a  vesicovaginal 
fistula,  the  imperforate  portion  of  the  vagina  may  be  opened  by 
a  transverse  incision,  the  rectum  and  bladder  being  guarded  by 
a  finger  in  the  one  and  a  sound  in  the  other.  In  a  case  of 
acquired  stenosis  of  the  vagina  in  which  the  canal  throughout  its 
whole  length  was  narrowed  to  a  sinus  barely  admitting  a  probe, 
the  author  was  obliged  to  do  a  Cesarean  section. 

Anns  vaginalis  or  vestibularis  may  complicate  labor  by  the 
accumulation  of  feces  in  the  rectum,  due  to  the  unnatural  position 
of  the  anus  (Fig.  410).  In  one  case  in  which  this  anomaly  was 
associated  wath  contraction  of  the  vulvar  orifice  it  was  necessary 
to  cut  the  perineal  structures  upward  from  the  rectum  toward  the 
pubis,  in  order  to  permit  the  escape  of  the  child's  head. 

Cystic  and  Solid  Tumors  of  the  Vagina  and  Vulva,  Edema, 
Elephantiasis,  Suppuration,  and  Gangrene. — In  the  case  of  solid 
tumors  excision  may  be  necessar\',  by  transfixing  the  pedicle  if 
the}"  have  one,  and  ligating  it  to  prevent  hemorrhage,  or  by  an 
incision  of  the  vaginal  wall  over  them  and  their  enucleation,  fol- 
lowed by  the  immediate  extraction  of  the  child,  and  the  control 
of  hemorrhage  b\'  the  needle  and  thread  or  by  direct  pressure. 
In  a  case  of  elephantiasis  vulvae  under  the  author's  care  there 
was  no  difficulty  in  labor.  The  labia  were  amputated  two  weeks 
afterward.  In  the  case  of  large  cystic  tumors  a  puncture  is 
sufficient  to  remove  the  obstruction.  Giider^  collected  60  cases 
of  vaginal  tumors  complicating  labor — 23  cysts  and  echinococcus 
sacs;  18  fibroids,  fibrom)-omata,  and  polypi;  14  carcinomata,  i 
sarcoma,  and  4  hematomata.  Delivery  was  accomplished  b}-  the 
following  diverse  methods:  Spontaneously,  14;  by  forceps,  18;  by 
version  and  extraction,  2  ;  by  traction  on  the  feet,  i  ;  b\'  removal 

1  Ahlfeld,  "  Zeitschrift  f.  Geburtsliiilfe  und  (lynakolojrie,"  Bd.  xxi,  p.  160; 
ibid.,  Bd.  .\iv,  p.  14. 

2  "  Ueber  Geschwiilste  der  Vagina  als  Scliwangerschaft  und  GeburtskompH- 
kationen,"  "  Diss.-Inaug. ,"  Bern,  1S89. 


536 


THE   PATHOLOGY  OF  LABOR. 


Fig.  411. — Cyst  of  the  right  labium  majus  (author's  case). 


Fig.  412. — Elephantiasis  vulvae  (author's  case) 


ANOMALIES  IN  THE    FORCES    OF  LABOR.  537 

or  puncture  of  the  tumor,  16;  by  Cesarean  section,  7;  by  induc- 
tion of  premature  labor  and  craniotomy,  2;  by  premature  labor, 
3  ;  by  laparo-elytrotomy,  i  ;  by  craniotomy  i  ;  by  pushing  back 
the  tumor  and  extracting  the  child  past  it,  2.  Among  the 
mothers  there  were  15  deaths;  among  the  children,  13.  In  11 
of  the  mothers  and  in  22  of  the  children  the  result  was  not 
reported. 

Edema  of  the  vulva  may  be  the  result  of  kidney  insufficiency 


* 

fj 

p 

-y 

1 

^ 

^ 

m 

1^^  * 

w 

Bk 

m^ 

^ 

ItSS^*^" " 

Fig.  413. — Edema  and  beginning  gangrene  of  the  vulva  from  prolonged  pressure  in 
an  obstructed  labor.      Cesarean  section  (author's  case). 

or  of  pressure  in  a  prolonged  labor.  The  increased  bulk  of  the 
dropsical  labia  may  interfere  with  the  escape  of  the  presenting 
part,  or,  what  is  more  likely,  the  edematous  tis.sues  lose  their 
elasticity,  obstruct  labor  by  their  rigidity,  and  arc  prone  to  deep 
tears  at  the  time  of  birth  and  to  gangrene  afterward.  Punctures 
or  incisions  in  the  labia  may  be  necessary  to  escape  more  serious 
injury,  but  it  is  well  to  avoid  them  if  possible,  for  they  are  apt  to 
be  followed  by  infection  and  gangrene. 

An  abscess  of  Bartholin's  gland  is  seldom  large  enough  to 
retard  labor,  though  it  has  done  so  (Miiller),  but  it  is  Hkel}'  to 
cause  trouble  afterward.  It  should  be  opened  freely  in  the  early 
part  of  the  first  stage  of  labor,  curetted,  swabbed  out  with  car- 
bolic acid  and  glycerin,  and  ]mcked  with  iodoform  gauze,  or,  l)cUcr, 
completely  c.xsected  by  a  dee-p  dissection. 

Gangrene  of  the  \ulva  is  very  rare  before  the  termination  of 
labor.  Should  it  exist,  it  might  determine  an  operator  in  favor 
of  Cesarean  section  in  a  doubtful  case,  on  account  of  the  rigidity 


538 


THE    PATHOLOGY  OF  LABOR. 


of  the  vulvar  tissues,  the  certainty  of  laceration,  and  the  likeli- 
hood of  grave  infection. 

Enlarged  Caruncidce  Myrtifonncs  and  Varicose  Veins. — These 
tumors  do  not  possess  sufficient  bulk,  as  a  rule,  seriously  to  ob- 
struct the  last  stage  of  labor.  They  may,  however,  be  so  bruised 
by  the  passage  of  the  head  as  to  slough  afterward,  or  the  veins  in 
them  may  be  ruptured,  giving  rise  to  subcutaneous  or  frank  bleed- 
ing of  an  alarming  character. 

Vaginismus  may  be  overcome  by  an  anesthetic.      Congenital 

narrotvness  of  the  vagina  and 
vulva  is  usually  overcome  by 
the  advance  of  the  presenting 
part,  though  often  at  the  ex- 
pense of  vaginal  and  perineal 
lacerations.  It  may  be  neces- 
sary to  resort  to  hydrostatic 
dilatation,  or  even,  in  rare  in- 
stances, to  Diihrssen's  plan  of 
multiple  incisions.  In  the  case 
of  extreme  narrowness  of  the 
vulva  there  may  be  a  central  tear 
of  the  perineum,  through  which 
the  presenting  part  begins  to 
emerge.  To  avoid  a  rectal  tear 
in  such  a  case  the  perineum 
should  be  cut  from  the  anterior 
border  of  the  perforation  to  the  posterior  commissure  of  the  vulva 
(Fig.   414). 

Rigidity  of  the  tissues  in  the  cervix,  the  vaginal  wall,  and  at 
the  outlet  occasions  delay  in  the  majority  of  all  primiparse,  but 
especially  in  the  case  of  elderly  primiparae — those  over  thirty 
years  of  age.  Eckhard  found  the  infantile  mortality  in  such  cases 
to  be  19.81  per  cent.,  the  maternal  mortality  to  be  three  times  as 
great  as  in  younger  primipar^  ;  and  the  necessity  for  operative 
interference  increases  steadily  with  the  age  of  the  primiparae  until, 
in  those  past  forty,  almost  two-thirds  are  delivered  by  some 
operative  procedure,  usually  forceps.  Craniotomy  should  be 
done  if  the  child  is  dead.  Version  is  the  least  successful  opera- 
tion in  these  cases. 

Displacements  of  the  Uterus. — The  uterus  in  labor  may  be 
displaced  forward  ;  to  either  side  ;  downward  ;  or  backward,  by 
the  so-called  "sacculation"  of  the  womb.  It  ma}' be  twisted  on 
its  pedicle,  the  cervix,  or  it  may  form  part  of  the  contents  of  a 
hernial  sac  in  inguinal  or  ventral  herniae. 


Fig.  414. — Central  tear  in  the 
perineum,  with  contracted  vulvar  ori- 
fice (Ribemont-Dessaignes). 


ANOMALIES   IN   THE  FORCES   OF  LABOR. 


539 


Anterior  Displacement  of  the  Uterus  in  Labor ;  Pejuiulous 
Belly. — This  is  a  common  anomaly  in  labor,  seen  to  some  degree 
in  all  cases  of  obstructed  labor,  as  in  deformed  pelvis,  and  in  all 
cases  in  which  the  length  of  the  abdominal  cavity  is  decreased, 
as  in  kyphosis.  A  peculiar  example  of  forward  displacement  is 
seen  in  those  rare  instances  of  hernia  of  the  parturient  womb 
between  the  recti  muscles  or  to  one  side  of  the  median  line  dur- 
ing the  second  stage  of  labor  (Fig.  415).      The  pregnant  womb 


Fig-  415-  —  Ilernia  of  the  gravid  womb  (Rosiiei). 

may  fall  forward  also  into  an  umbilical   hernia  or  into  a  ventral 
hernia  following  celiotomy. 

The  removal  of  the  obstruction  to  labor  in  the  fust  class 
of  cases  ordinarily  obviates  the  anterior  displacement.  If  the 
displacement  depends  not  upon  ob.struction.  l)iit  upon  llaccid 
abdominal  walls,  the  a])i)lication  of  an  aljdomiiial  binder  cor- 
rects the  anteversion.  In  cases  of  hernia  of  the  uterus  lhr()u,<i;h 
the  anterior  abdominal  wall,  artificial  delixery  with  forceps  or  by 


540 


THE   PATHOLOGY  OF  LABOR. 


version  may  be  necessary;  when  the  uterus  is  evacuated,  it  can 
easily  be  returned  into  the  abdominal  cavity.  A  tight  abdominal 
binder  and  the  diminution  of  intra-abdominal  pressure  after  de- 
livery promotes  the  approximation  of  the  separated  recti 
muscles.  In  inguinal  hernia  the  pregnant  womb  in  the  hernial 
sac  is  usually  unicorn  or  bicorn  (Fig.  416).  Delivery  may  be 
effected  by  version,  and  this  may  be  followed  by  a  reduction  of 
the  hernia,  but  it  is  best  to  lay  open  the  sac,  incise  the  womb, 
extract  its  contents,  and  then  amputate  it.  Adams  ^  has  collected 
ten  cases  of  inguinal  hernia  of  the  gravid  womb,  including  Dorin- 
gius's,  which  he  calls  "  crural."  In  eight  Cesarean  section  was 
done  ;  in  one  the  delivery  was  spontaneous. 

Labor  Complicated  by  a  Former  Operation  to  Suspend  or  Fix 
the  Womb  Anteriorly. — The  number  of  operations  performed  for 
posterior  displacement  of  the  uterus  on  women  of  child-bearing 
age  has  become  so  large  of  recent  years  that  ample  opportunity 
has  been  afforded  to  judge  of  the  influence  of  anterior  fixation 


Fig.  416. — Inguinal  hernia  containing  a  gravid  womb  (Winckel). 


and  suspension  of  the  uterus  on  pregnancy  and  childbirth.  Dor- 
land  ^  has  collected  the  statistics  of  1 79  pregnancies  following 
operations  for  ventrosuspension,  ventrofixation,  and  vaginal  fixa- 
tion. It  appears  from  these  statistics  that,  the  firmer  the  womb 
is  fixed  and  the  lower  the  fundus  is  fastened,  the  more  certainly 
will   there  be  serious  disturbances  in  pregnancy  and  dangerous 

1  Adams,    "Hernia  of  the   Pregnant  Uterus,"  "  Amer.    Jour.    Obstetrics,"  vol. 
xxii,  p.  225.  2  <«  University  JMed.  Mag.,"  Dec,  1896. 


ANOMALIES  IN  THE   FORCES    OF  LABOR.  54 1 

complications  in  labor.  Thus,  abortion  occurred  in  14  per 
cent,  of  the  ventrosuspensions  and  in  27  per  cent,  of  the  vaginal 
fixations.  In  12.29  per  cent,  of  all  the  cases  there  was  dys- 
tocia, requiring  in  three  instances  Cesarean  section.  The  com- 
plications noted  in  labor  were  :  inertia  uteri,  transverse  position 
of  the  child,  abnormal  positions  of  the  head,  cervical  rigidity, 
uterine  rupture,  placental  anomalies,  postpartum  and  puerperal 
hemorrhages,  and  a  mechanical  obstruction  in  labor  from  the 
thick  anterior  wall  of  the  uterus,  held  firmly  down  over  the  pelvic 
inlet,  the  distention  of  the  uterus  in  pregnancy  having  been  accom- 
plished by  the  expansion  mainly  of  the  posterior  uterine  wall. 
Pregnancy  was  seriously  disturbed  in  8.37  per  cent,  of  the  cases, 
not  including  those  in  which  abortion  occurred,  by  pain  and  trac- 
tion at  the  site  of  the  incision,  dysuria,  and  excessive  nausea  and 
vomiting. 

A  sure  indication  of  the  difficulty  to  be  expected  in  labor  is 
afforded  by  the  behavior  of  the  fundus  and  cervix  of  the  womb  in 
pregnancy.  If  the  former  remains  fixed  over  the  pelvic  inlet  and 
the  latter  is  steadily  drawn  upward  and  backward  until  it  reaches 
the  promontory  of  the  sacrum  or  actually  ascends  above  it,  the 
labor  will  be  so  seriously  complicated  in  all  probability  that, 
in  the  hands  of  an  expert  abdominal  surgeon,  the  best  results 
may  be  obtained  by  opening  the  abdomen  and  severing  the  ad- 
hesions between  the  fundus  uteri  and  the  abdominal  wall.  If 
version  is  demanded  in  labor  at  term,  great  care  must  be  exercised 
not  to  rupture  the  overstretched  posterior  uterine  wah. 

The  best  preventive  treatment  of  difficulty  in  pregnancy  and 
labor  after  the  operative  treatment  for  posterior  displacement  is 
the  choice  of  the  appropriate  operation  and  its  proper  perform- 
ance. Vaginal  fixation  should  not  be  selected.  Shortening  of 
the  round  ligaments  has  not  yet  given  rise  to  any  difficulty  in 
subsequent  pregnancies  and  labors,^  nor  has  ventrosuspension, 
properly  performed.  If  the  operator  uses  fine  celloidin  linen  thread 
and  includes  only  a  portion  of  the  rectus  muscle  with  the  peritoneum 
in  the  abdominal  portion  of  the  stitch,  the  artificial  suspensory 
ligament  is  so  flexible  and  stretches  so  easily  that  no  difficulty 
need  be  apprehended  if  the  patient  conceives.  In  more  than  700 
operations  by  the  author  for  retrodisplacement  there  has  been  only 
one  case  in  which  there  was  a  complication  traceable  to  the  opera- 
tion in  pregnancy  and  labor,  and  this  was  not  much  more  than 
serious  inconvenience  during  the  first  six  months  of  pregnancy  from 
drag  upon  the  suspensory  ligament. 

'  Stratz  has  reported  one  case  of  difficulty  from  a  thickened  inllamed  right  round 
ligament,  but  the  woman  had  gall-stones  and  jaundice,  and  it  is  not  clear  that  the 
symptoms  were  referable  to  a  former  Alexander  operation.  "  Centrbl.  f.  Gyn.,"  No. 
28,  1900. 


542 


THE  PATHOLOGY  OF  LABOR. 


Lateral  Displacement. — A  tilting  of  the  uterus  to  the  right  side 
is  a  physiological  occurrence  in  pregnant  and  parturient  women. 
The  lateral  inclination  is  sometimes  exaggerated  to  such  a  degree 
that  a  great  part  of  the  expulsive  force  is  lost  by  the  propulsion 
of  the  presenting  part  against  the  lateral  wall  of  the  pelvis.  The 
displacement  may  be  corrected  by  turning  the  woman  on  the 
side — usually  the  right — toward  which  the  fundus  uteri  is  in- 
clined, and  placing  under  her  flank  a  rolled  blanket  or  a  pillow. 

Sacculation  of  the  Uterus. — A  backward  displacement  of  the 
gravid  womb  in  rare  cases  goes  on  to  full  development  by  what 
is  called  "posterior  sacculation,"  the  distention  of  the  uterus  to 
accommodate  the  full-grown  fetus  being  accomplished  by  stretch- 
ing the  anterior  uterine  wall,  the  posterior  wall  and  the  fundus 

remaining  fixed  within  the  pelvis 
(Fig.  419).  In  these  cases  the 
cervix  is  high  above  the  pelvic 
inlet  and  is  pressed  close  against 
the  anterior  abdominal  wall,  the 
posterior  vaginal  wall  bulges  out- 
ward and  downward,  and  fetal 
parts  can  be  felt  through  it  with 
a  distinctness  that  suggests  ab- 
dominal pregnancy.  Cesarean, 
section  has  been  performed  on 
account  of  this  anomaly,  but  a 
study  of  recorded  cases  shows 
it  to  be,  as  a  rule,  unneces- 
sary. By  the  artificial  dila- 
tation of  the  cervical  canal 
and  the  performance  of  podalic 
version,  delivery  maybe  effected 
without  difficulty. 

Partial  Prolapse  ivitli  Hyper- 
trophic Elongation  of  the  Cervix. 
— It  is  impossible  for  pregnancy 
to  proceed  to  term  with  com- 
plete prolapse  of  the  womb, 
although  the  size  of  the  uterine 
tumor  projecting  from  the  vulva  in  some  cases  has  given  rise  to 
a  belief  in  this  possibility  (Fig.  417).  A  careful  examination  has 
always  shown  the  major  portion  of  the  uterine  body  to  be  within 
the  pelvic  and  abdominal  cavities.  Commonly,  the  fundus  is  at  a 
normal  level,  and  the  descent  of  the  cervix  has  been  accomplished 
by  stretching  the  lower  uterine  segment  and  by  hypertrophic 
elongation   of  the   cervix   itself      When  the  contraction   of  the 


Fig.  417- — Partial  prolapse  of  the  womb 
in  labor  (Wagner). 


ANOMALIES  IN   THE   FORCES   OF  LABOR. 


543 


uterine  muscle  begins  in  labor,  a  partial  prolapse  of  the  womb  is 
usually  spontaneously  corrected  by  the  retraction  of  the  cervix 


Fig.  418. — Prolapse  of  a  double  uterus  in  a  pregnant  woman  (IMaygrier) 


Fig-  419- — Sacculation  of  the 
uterus  (Oldham). 


Fig.   420. — Partial    prolapse   of  the 
womb    and    hypertrophy    ©f    the    cervi.\ 

(Faivre). 


within  the  vagina.  This  the  author  has  seen  in  several  instances. 
In  exceptional  ca.scs,  however, — usually  on  account  of  a  rigid 
cervix, — the  prolapse  becomes  aggravated  or  suddenly  makes  its 


544 


THE   PATHOLOGY  OF  LABOR. 


appearance,  and  the  cervical  tissues,  growing  edematous  and  be^ 
coming  enormously  swollen,  constitute,  by  their  bulk  and  in- 
creased rigidity,  a  serious  obstruction  to  the  delivery  of  the  child. 


Fig.  421. — Displacement  of  the  cervix  (Dickinson). 


This  difficulty  was  overcome  in  an  ingenious  manner  in  a  case 
reported  by  Faivre.'  The  w^oman  was  placed  in  the  dorsal  posi- 
tion across  the  bed,  a  forceps  was  applied  to  the  child's  head,  and 
an  assistant,  standing  astride  the  woman's  body,  hooked  his  fingers 
into  the  cervix  and  pulled  upward  to  counteract  the  traction  of 
the  forceps  upon  the  child's  head  and  the  incarcerated  cervical 
tissues.  It  may  be  necessary  in  such  a  case  to  enlarge  the  cervical 
canal  by  radiating  incisions.  The  hemorrhage  following  is  con- 
trolled temporarily  by  clamping  sutures  over  the  wounded  surfaces 
without  uniting  them  (Fig.  420). 

Displacement  of  the  Cervix. — It  is  not  uncommon,  in  prim- 
iparae  with  a  narrow  cervical  canal,  for  the  cervix  to  be  displaced 
backward,  so  that  the  external  os,  almost  inaccessible  to  the  ex- 
amining finger,  points  directly  backward  or  even  backward  and 
upward.  The  anterior  lower  uterine  segment  is  much  distended 
1  "Nouvelles  Archives  d'0bst6trique,"  1890. 


ANOMALIES   IN   THE   FORCES    OF  LABOR.  545 

by  the  presenting  part  and  occupies  the  whole  vaginal  vault.  The 
expulsive  force  in  labor  is  exerted  against  the  lower  uterine  seg- 
ment, and  the  cervical  canal  remains  undilated.  The  difficulty  may 
be  overcome  by  applying  an  abdominal  binder  and  by  hooking  the 
cervix  forward  with  the  finger  during  two  or  three  pains  (Fig.  421). 

Tumors  of  the  Genital  Canal. — Carcinoma  of  the  Cervix. — In 
34  per  cent,  of  the  cases  cancer  of  the  cervix  interrupts  gestation 
at  various  stages  (Miiller).  If  the  disease  is  not  too  far  ad- 
vanced ;  if  it  is  confined  to  one  lip  of  the  cervix,  and  that  the 
anterior ;  and  if  there  is  not  too  much  cicatricial  infiltration 
around  its  periphery  and  the  cervical  walls,  labor  may  be  ter- 
minated spontaneously,  but  this  is  exceptional.  The  per- 
formance of  Cesarean  section  is  commonly  the  proper  treat- 
ment for  labor  obstructed  by  carcinoma  of  the  cervix,  and  this 
operation  should  be  selected  if  there  is  good  reason  to  doubt  the 
possibility  of  spontaneous  or  artificially  assisted  delivery  by  the 
natural  passage-way.  If  the  disease  is  far  advanced,  the  woman's 
life  is  surely  doomed  in  the  near  future,  and  the  child  at  any  rate 
should  be  saved,  even  at  considerable  risk  to  the  mother.  It  may 
be  desirable  to  operate  before  the  fetus  has  reached  maturity,  if 
the  disease  is  making  such  rapid  progress  that  the  woman  is 
likely  to  die  before  the  natural  end  of  pregnancy,  or  if  the  cancer 
is  still  in  the  operable  stage.  An  abdominal  or  vaginal  pan- 
hysterectomy should  follow  the  Cesarean  section,  if  possible. 

Fibromata. — Fibroids  of  the  uterus  and  cervix  low  enough 
in  situation  to  become  incarcerated  in  the  pelvis  are  likely  to 
be  insuperable  obstructions  in  labor,  besides  complicating  par- 
turition by  favoring  abnormal  positions  of  the  child,  by  pre- 
disposing to  adherence  of  the  placenta,  to  prolapse  of  the  ex- 
tremities and  cord,  to  hemorrhage  during  and  after  labor  and  to  in- 
fection. If  the  tumor  grows  on  the  anterior  wall  of  the  uterus,  the 
first  few  labor-pains  and  the  contraction  of  the  longitudinal  fibers  of 
the  cervix  may  dislodge  it  above  the  pelvic  brim,  though  it  had 
been  impossible  to  do  this  before  by  manipulation.  It  is  also  ])os- 
sible  for  tumors  on  the  anterior  wall  of  the  cervix  to  be  pushed  out 
of  the  vulva  in  front  of  the  presenting  jjart,  thus  making  room  for 
the  escape  of  the  latter.  If,  however,  the  tumor  is  situated  laterally 
or  posteriorly,  its  artificial  displacement  upward  into  the  abdominal 
cavity,  so  that  the  child  may  escape  ])ast  it,  is  often  imj)racticable 
(Fig.  422).  On  the  contrary,  the  attempt  at  descent  of  the  present- 
ing ])art  in  labor  may  fix  it  more  firmly  in  the  ])elvic  ca\-ity.'     In 

'  II  is  barely  possible  that  a  tumor  low  down  on  ihc  ]iosterior  wall  of  the  cervix, 
tlie  most  unfavorable  of  all  positions,  may  be  suddenly  elevated  after  many  hours  of 
labor,  and  thus  allow  a  spontaneous  delivery  ;  but  this  event  is  not  to  be  counted  on 
in  practice. 

35 


546 


THE   PATHOLOGY  OF  LABOR. 


this  case,  if  attempts  under  anesthesia  to  dislodge  the  tumor  and 
to  push  it  above  the  peh'ic  brim  fail,  a  Porro-Cesarean  opera- 
tion should  be  performed,  even  though  the  tumor  is  not  so 
large  as  absolutely  to  prevent  the  delivery  of  the  child.  The 
physician  must  consider  the  effect  upon  it,  owing  to  its  low 
vitality,  of  the  pressure  to  which  it  will  be  subjected  by  dragging 
the  child  past  it  (Fig.  423).     Sloughing,  gangrene,  and  fatal  in- 


Fig.  422. — Large  fibroid  blocking  the  pelvis  (SpiegelbergJ. 


fection  are  hkely  to  follow.  This  was  the  history  of  the  case 
illustrated  in  figure  423,  communicated  to  the  author  by  Dr.  J.  P. 
Simpson,  of  South  Carolina.  If  the  fibroid  is  submucous  and 
grows  from  the  cervix,  it  may  be  enucleated  when  labor  begins. 
The  bed  of  the  tumor  should  be  packed  with  gauze  after  labor.  1 
It  is,  unfortunately,  a  common  error  to  overlook  a  fibroid 
tumor  obstructing   the  pelvis   in  labor,  or  to   mistake  it  for  the 

1  Sutugin  is  an  enthusiastic  advocate  of  vaginal  operations  for  all  cases  of  fibroids 
impacted  in  the  small  pelvis.  For  intramural  tumors  the  cervix  is  split  until  the 
tumor  is  reached.  For  subserous  tumors  the  vaginal  vault  is  opened.  Nine  such 
operations  .f///^ /r?;//^  are  reported  with  only  one  death  (Jahresb.  ii.  d.  Fortsch.  a.  d. 
Gebiete  der  Geburtsh.,"  etc.,  vol.  v,  p.  175). 


ANOMALIES   IN    THE   FORCES    OF  LABOR. 


547 


fetal  head.  The  woman  is  allowed  to  die  of  ruptured  uterus, 
exhaustion,  or  hemorrhage,  while  the  physician  is  waiting  for  the 
descent  of  the  presenting  part,  or  is  endeavoring  to  apply  the 
forceps  to  what  he  takes  to  be  the  head.  Ordinary  care  and 
a  little  experience  in  making  obstetrical  examinations  should 
guard  a  practitioner  against  such  an  egregious  mistake. 

The  prognosis  o(  labor 
complicated  by  a  fibroid 
tumor  depends  upon  the 
early  recognition  of  the 
growth  and  upon  the 
treatment.  In  general 
practice  the  results  have 
hitherto  been  bad.  Nauss 
found  a  maternal  mor- 
tality of  54  per  cent, 
among  225  women  and 
an  infantile  mortality  of 
57  per  cent,  in  117  cases. 
Siisserott  found  in  147 
cases  a  maternal  mor- 
tality of  50  per  cent,  and 
an  infantile  mortality  of 
66  per  cent.^ 

In  Lefour's  statistics 
of  300  cases  of  fibroids 

complicating     labor,     the    and  the  woman  died  (Simpson). 

mortality  of  delivery  by 

the  natural  passage  was   25   to  55  per  cent,  for  the  mothers,  yy 

per  cent,  for  the  children.^ 

A  fibroid  tumor  may  prolapse  into  the  pelvis  after  the  birth 
of  the  child  and  prevent  the  delivery  of  the  placenta.  The  au- 
thor has  performed  Cesarean  section  (Porro)  twice,  myomectomy 
twice,  and  hysterectomy  four  times  in  the  puerperium  for  fil)roids 
compHcating  the  chikl-bearing  process  without  a  death,  although 
in  four  cases  the  tum.or  was  necrotic. 

The  tumor  may  practically  disappear  during  the  involution 
of  the  uterus.  Every  year  the  author  sees  a  case  or  two  of  spon- 
taneous cure  in  this  way.  There  is,  however,  a  strong  disposi- 
tion to  infection  after  labor  in  the  weakly  resisting  structure  of  a 
fibromyoma. 

1  Sutugin,  loc.  cit.  A  valuable  table  of  statistics  showing  the  result  of  various 
treatments  for  fibroids  in  the  chikl-bearing  process  was  presented  by  .\rmand  Routh 
at  the  British  Medical  Association  Meeting  in  iqo;^.  See  al.-^o  Tate,  ".\m.  Jnurn.  of 
Obst.,"  November,   igo2;    Partridge,  "  Trtn-.   Med.  Journ.,"  Sept.,  1903. 

■'■  Phillips,  "  llrit.  Med.  Jnurn'.,"   188S,  i,  p.  331. 


Fig.  423. — Small  fibroid  past  which  the  child 
extracted.      The    tumor    became   gangrenous, 


548  THE   PATHOLOGY  OF  LABOR. 

Polypi. — Polypoid  tumors  obstructing  labor  usually  spring 
from  the  cervical  canal  or  the  anterior  lip  of  the  cervix,  and  are 
commonly  mucous  in  character.  They  may,  however,  be  fibro- 
myomatous,  fibrous,  or  sarcomatous,  and  may  have  a  situation 
high  in  the  uterine  cavity  or  in  its  wall.  They  may  increase  Very 
markedly  in  size  during  pregnancy.  The  pedicle  is  usually  small, 
and  in  the  case  of  cervical  polypi  their  removal  is  easy.  The  opera- 
tion should  be  postponed,  however,  until  the  woman  falls   into 


Fig.  424. — Large  subperitoneal  fibroma  reaching  from  the  fundus  uteri  to  the  liver; 
removed  by  myomectomy  on  tenth  day  of  puerperium  for  infection  ;^ recovery). 

labor,  for  any  operative  interference  in  this  region  w^ould  very 
likely  interrupt  gestation.  When  the  dilatation  of  the  os  begins, 
the  pedicle  may  be  transfixed  and  ligated  and  the  tumor  be  cut 
away.  Even  if  these  growths  are  not  sufficient  in  bulk  to  obstruct 
parturition  mechanically,  they  have  been  known  to  give  rise  to 
profuse  hemorrhage  in  the  first  few  days  of  the  puerperium,  and 
their  removal  is  desirable,  therefore,  even  though  they  be  small 
in  size.  In  the  case  of  fibromyomatous  polypi  of  the  uterine 
body,  the  tumor  has  on  rare  occasions  been  torn  from  its  pedicle 
during  labor  and  has  been  expelled  in  front  of  the  child. 

The   non=pregnant   half  of    a   uterus   bicornis  or  didelphys   may 
hypertrophy  to  such  an  extent  as  to  obstruct  labor,  cause  rupture 


ANOMALIES'  IN   THE   FORCES    OF  LABOR. 


549 


of  the  pregnant  uterus,  or  demand  Cesarean  section.  If  the  nature 
of  the  obstruction  is  recognized,  the  non-pregnant  portion  of  the 
uterus  may  be  pushed  out  of  the  way.  If  this  is  impossible,  Cesa- 
rean section,  followed  by  amputation  of  the  non-pregnant  side 
of  the  uterus,  is  indicated.^ 

Tumors  of  Neighboring  Organs. — Ovarian  Cysts. — An  ovarian 
cyst  is  a  rare  comphcation  of  labor.  In  17,832  births  in  the 
Berlin  Frauenklinik,  an  ovarian  cyst  was  found  only  five  times. 
McKerron,^  however,  was  able  to  collect  1290  cases  of  ovarian 
tumor  comphcating  the  child-bearing  process.  The  number 
of  abortions  in  pregnancies  comphcated  by  ovarian  cysts  is  some- 
what  larger   than    common.     Of    321    pregnancies    complicated 


Fig.  425. — Subperitoneal  fibromata.  The  growth  attached  to  the  lower  uterine 
segment  was  impacted  in  the  pelvis,  insuperably  obstructing  labor.  Celiohysterecto- 
my :  woman  recovered,  although  she  had  been  in  labor  four  days ;  child  dead 
(author's  case). 

by  ovarian  cysts,  tliere  was  premature  interruption  in  55  (Remy). 
If  the  cyst  is  discovered  during  ])regnancy,  its  removal  should  be 
attempted.     Ovariotomy   during    gestation    is    not    necessarily    a 

^  G.  S.  Brown,  "  Surger)-,  (iyn.  and  Obstet.,"  Sej)tember,  igo6. 

2  '<  I^regnancy,  Labor  and  C'liildbed  with  Ovarian  Tumor,"  London,  1903. 


550 


THE   PATHOLOGY  OF  LABOR. 


difficult  or  dangerous  operation,  nor  does  it,  as  a  rule,  interrupt 
pregnancy.^  If  the  tumor  is  first  discovered  after  the  woman 
has  fallen  into  labor,  and  if  it  has  been  displaced  downward  into 
the  pelvic  cavity  and  is  incarcerated,  resisting  all  efforts  to  dis- 
place it  upward,  even  under  anesthesia,  it  is  better  to  perform 
a  Cesarean  section,  followed  by  the  removal  of  the  tumor.-  By 
this  plan  many  dangers  in  the  puerperium  are  escaped.  Twisted 
pedicle,  intracystic  bleeding  and  shock,  occlusion  of  the  bowels, 
rupture  of  the  cyst,  suppuration  of  the  cyst-contents,  and  conse- 
quent peritonitis  are  all  surely  avoided.  A  number  of  cases  treated 
thus  should  give  a  better  mortality  record  than  has  hitherto  been 


Fig.  426. — Dermoid  cyst  containing  hair  and  teeth  and  puerperal  uterus,  removed  in 
a  Porro- Cesarean  section  (author's  case). 

secured.  Another  plan  of  treatment  which  has  yielded  good  results 
is  vaginal  ovariotomy,  if  the  .tum.or  is  of  m.oderate  size.  The 
posterior  vaginal  vauk  and  Douglas'  pouch  are  opened,  the  tumor 
is  punctured  and  extracted  collapsed,  the  pedicle  is  ligated,  and  the 

'  Dsirne  has  collected  statistics  of  I35  operations  with  a  mortality  of  5.9  per 
cent.  Pregnancy  is  interrupted  by  the  operation  in  about  20  per  cent,  of  cases 
(Flaischlen,  "  Zeitschrift  f.  Geburtshiilfe,"  xxix,  p.  49).  Heil's  statistics  of  241 
operations  gives  a  mortality  of  2. 1  per  cent,  and  interrupted  pregnancy  in  19.47  per 
cent.  ("Miinch.  med.  Wochenschr.,"  Jan.  19,  1904). 

^  I  have  performed  Cesarean  section  twice  for  large  dermoids  impacted  in  the 
pelvis  obstructing  labor,  with  a  successful  result  for  both  mother  and  child.  My 
experience  in  ovarian  cysts  complicating  the  childbearing  process  amounts  to  ten 
operations  in  nine  individuals:  two,  small  dermoids,  removed  in  pregnancy;  3 
operated  on  in  labor  ;  2  Cesarean  sections  :  one  vaginal  puncture,  the  latter  being  a 
mullilocular  cyst,  the  two  former,  dermoids  ;  5  removed  in  the  puerperium  on 
account  of  infection.  One  of  the  last  named  died  from  septic  intoxication,  the  only 
fatal  result.  One  was  removed  on  the  sixth  day  of  the  puerperium  on  account  of 
gangrene  and  peritonitis,  the  result  of  a  twisted  pedicle. 


ANOMALIES  IN  THE   FORCES    OE  LABOR.  55  I 

tumor  excised.  The  vaginal  wound  is  either  packed  with  gauze 
and  united  after  delivery  or  closed  before  the  extraction  of  the  child. 
In  Heiberg's  statistics  of  271  cases  there  was  a  maternal  mortality 
in  pregnancy  of  more  than  25  per  cent,  and  a  fetal  mortaUty  of 
more  than  66  per  cent.  In  deliveries  by  forceps  without  puncture 
of  the  cyst  the  maternal  death  rate  has  been  50  per  cent.;  with 
puncture,  almost  as  great;  and  after  version  without  puncture, 
more  than  50  per  cent.  Flaischlen  recommends  the  vaginal  punc- 
ture, or,  if  necessary,  a  vaginal  incision  and  thorough  evacuation 
of  the  tumor,  then  the  delivery  of  the  child,  and  on  the  following 
day,  at  the  latest,  an  abdominal  section  for  the  removal  of  the  tumor. 
This  procedure  does  not  seem  to  me  so  good  a  plan  as  the  coinci- 
dent Cesarean  section  and  ovariectomy.  Should  the  physician 
prefer  ^'aginal  puncture — which  requires,  of  course,  no  special 
surgical  skill — he  should  remember  that  if  the  tumor  is  densely 
adherent,  possesses  thick  walls,  and  possibly  is  a  dermoid  cyst, 
puncture  through  the  vaginal  vault  is  likely  to  be  followed  by  gan- 
grene of  the  tumor  contents  and  walls  and  by  general  infection. 
The  infection  of  the  tumor  necessitates  a  hurried  abdominal  section 
in  the  puerperium-,  with  the  patient  in  a  bad  condition  to  endure  it. 
Moreover,  if  the  cyst  is  multilocular,  it  may  be  impossible  to  reduce 
its  size  sufficiently  by  vaginal  puncture  to  permit  the  delivery  of  a 
living  infant.  The  author  has  experienced  both  the  disadvantages 
of  this  plan  of  treatment. 

It  has  been  claimed  that  an  ovarian  cyst  obstructing  labor 
should  be  removed  by  celiotomy  and  that  then  the  labor  should 
be  terminated  by  the  natural  passage,  but  to  subject  a  woman  to 
a  labor  that  might  prove  tedious  and  exhausting  or  might  require 
a  difficult  forceps  operation  directly  after  an  abdominal  section 
is  not  good  surgical  judgment. 

Spontaneous  delivery  in  spite  of  an  ovarian  cyst  incarcerated 
in  the  pelvis  has  been  noted  after  the  cyst  ruptured,  after  it  had 
been  spontaneously  dislodged  upward  above  the  pelvic  brim,  or 
had  ruptured  the  vaginal  vault  or  the  rectum.  As  an  ovarian 
cyst  must  be  impacted  in  the  pelvis  to  obstruct  the  deliverv  of 
tlie  child,  it  is  easily  understood  that  there  is  more  difficulty  and 
danger  in  labor  from  a  small  than  from  a  large  tumor  (Fig.  427). 
After  the  child  is  born,  a  cyst  that  had  before  been  above  the 
brim  may  descend  into  the  pelvis  and  obstruct  the  delivery  of 
the  placenta. 

If  the  ovarian  cyst  has  not  been  remo\'ed  during  pregnancy, 
is  in  the  upper  part  of  the  abdomen,  out  of  the  way  in  labor,  it 
may  be  disregarded  until  the  woman  is  delivered.  It  is  good 
practice  to  remove  it  in  the  first  48  hours  of  the  puerperium,  thus 


552 


THE   PATHOLOGY  OF  LABOR. 


avoiding  the  possibility  of  twisted  pedicle  and  infection,  or  at  the 
latest  as  soon  as  the  puerperal  convalescence  is  completed. 

Vaginal  Enterocele . — Vaginal  hernia  is  a  very  rare  obstruction 
in  labor.  The  author  has  been  able  to  collect  but  27  cases  from 
medical  literature.  Of  these,  only  two  were  anterior  entero- 
celes  ;  the  others  were  lateral  and  posterior.  The  distention  of  the 
hernial  sac  in  labor  is  apt  to  become  excessive,  and  to  threaten 
its  rupture  with  protrusion  of  intestinal  loops.  An  effort  should 
be  made  to  reduce  the  hernia  as  soon  as  it  is  discovered.  The 
reduction  may  be  facilitated  by  placing  the  woman  in  the  knee- 
breast  posture  and  by  inserting  the  whole  hand  into  the  vagina. 
If  this  treatment  is  instituted  in  pregnancy,  it  should  be  followed 
by  the  insertion  of  a  large  tampon  or  a  globe  pessary  and  by  pro- 
longed rest  in  bed  ;  in  labor  the  presenting  part  should  imme- 
diately be  brought  down  past  the  hernial  ring.  If  there  are 
adhesions  about  the  latter,  preventing  the  reduction  of  the  hernia. 


Fig.  427. — Ovarian  tumor  incarcerated 
in  the  pelvis  during  labor. 


Fig.  428. — Cystocele  obstructing  labor. 


the  tumor  should  be  supported  and  held  to  one  side  by  assistants 
while  the  child  is  artificially  extracted  by  forceps  or  after  version. 
Should  the  sac  rupture  and  the  intestines  protrude,  the  child 
must  be  delivered  hastily,  the  intestines  be  cleansed  thoroughly 
and  replaced,  and  the  opening  be  sewed  up.  In  the  case  of  a 
very  large  irreducible  vaginal  hernia.  Cesarean  section  would 
be  preferable  in  a  labor  at  term. 

Other  growths  or  tumors  in  the  pelvic  inlet  and  cavity  obstruct- 
ing labor  have  been  fibrocystic  tumors  of  the  ovarian  ligament,  re- 
quiring an  abdominal  section  ;  fibroma  of  the  ovary ;  sarcoma  of  the 
ovary;  a  displaced  adherent  kidney  at  the  pelvic  inlet,  necessitat- 
ing version  and  forcible  extraction,  or  possibly,  as  was  done  sue- 


ANOMALIES  IN   THE  FORCES   OF  LABOR.  553 

cessfully  by  Cragin,  vaginal  section  and  removal  of  the  turner;^ 
hydatid  cvsts  of  the  pelvis,  demanding  Cesarean  section;"  a  dis- 
placed and  enlarged  spleen;  masses  of  exudate,  caseous  lymph 
glands,  and  an  aneurysm  of  the  gluteal  artery. 

A  cystocele  and  a  rectocele  should  be  replaced  if  they  pro- 
trude to  a  great  extent  in  front  of  the  head,  and  should  be  held 
back  until  a  forceps  is  applied  and  the  head  is  pulled  past  them 
(Fig.  428).  Version  and  extraction  have  occasionally  been 
found  necessary.  Large  fecal  masses  in  the  rectum  must  be  re- 
moved by  an  enema  or  must  be  dug  out.^  Calculi  in  the  blad- 
der should,  if  possible,  be  discovered  and  removed  by  the  urethra 
or  by  vaginal  lithotomy  before  the  second  stage  of  labor.  They 
may  become  nipped  between  the  head  and  the  pubic  bones,  and 
may  pinch  a  hole  through  the  anterior  vaginal  wall  and  bladder 
if  they  are  overlooked  or  neglected.*  The  diagnosis  of  vesical 
calculus  in  the  parturient  woman  is  difhcuh :  it  has  been  taken  for 
a  pelvic  exostosis  or  some  other  pelvic  tumor,  and  in  one  case  at 
least  Cesarean  section  was  performed  on  account  of  this  mistake. 
Fortunately,  vesical  calculus  in  the  female  is  rare.  In  10,000 
women  examined  by  Winckel  in  fifteen  years,  it  was  found  only 
once. 

The  following  conditions  in  and  about  the  rectum  may  pre- 
sent mechanical  obstacles  to  delivery  :  Cancer,  anus  vestibularis 
or  vaginalis,  foreign  bodies,  contraction  of  the  levator  ani  mus- 
cles, benignant  tumors,  such  as  cysts  of  the  rectum,  ovarian  cysts 
which  have  perforated  the  rectum,  and  retrorectal  dermoid  cysts. 
Each  of  these  conditions  must  be  treated  according  to  the  indi- 
vidual indications.  Incisions  in  the  perineum  may  be  required, 
foreign  bodies  must  be  removed,  resisting  muscles  on  the  pelvic 
floor  may  be  overcome  by  an  anesthetic  and  b}^  the  application 
of  forceps,  and  cystic  tumors  should  be  punctured  or  removed 
after  ligation  of  their  pedicles.  Cancer  of  the  rectum  may  de- 
mand Cesarean  section  by  reason  of  the  size  of  the  tumor  and 
the  cicatricial  infiltration  of  the  birth-canal,  as  in  Freund's 
case. 

1  Runge  reports  four  cases  ("  Archiv  f.  Gyn.,"  xli.  p.  99).  The  writer  lias  had 
one.  Albers-Sclioenberg  reports  another  in  which  the  uterus  ruptured  (  "  Centralhlatt 
f.  Gyn.,"  Dec.  i,  18941.  Cragin  has  collected  six  cases  including  his  own  ("Am. 
Jour,  of  Obstet.,"  vol.  xxxviii,  p.  37). 

2  "  Les  Kystes  Ilydatiques  du  Bassin  et  de  I'Abdomen  au  point  de  vue  de  la 
dystocie,"  J.  Franta,  "Ann.  de  Gyn.  etd'Obstet,"  Mar.,  1902. 

*  Corradi  reports  a  case  in  which  seven  pounds  of  liardened  feces  were  removed 
before  the  woman  was  delivered. 

*  Kotschurowa  has  rejiorted  a  ca.se  in  which  labor  lasted  three  days.  At  the 
end  of  that  time  a  gangrenous  tumor  protruded  from  the  vulva,  which  proved  to 
be  the  bladder  and  anterior  vaginal  wall.  The  midwife  in  attendance  jjcrforaled 
the  tumor  with  her  finger,  whereupon  a  calculus  eighty-five  grains  in  weight  was  dis- 
charged (  "  Jahresbericht  ii.  d.  Fortschr.   a.  d.  Gebiete  der  Geburtsh.,"'  eic,  vi,  225) 


554 


THE   PATHOLOGY  OF  LABOR. 


Obstruction    in    Labor  on  the    Part  of    the   Fetus. — Over= 

growth  of  the  Fetus. — Excessive  overgrowth  of  the  fetus  is  rare. 
In  I  GOO  children  in  the  ^Maternity  Hospital  of  Philadelphia  only 
one  weighed  more  than  12  pounds.  The  largest  child  the  author 
has  ever  seen  weighed  15  pounds,   weights  of  15,  16,  18,  23^,  and 

28f  pounds  have 
been  recorded. 
The  causes  of 
o^'ergrowth  in 
the  fetus  are 
prolongation  of 
pregnancy,  over- 
size and  ad- 
vanced age  of 
one  or  both  par- 
ents, and  multi- 
parity.  Rarely, 
it  may  be  inex- 
plicable. The 
first  named  is, 
in  the  writer's 
experience,  the 
most  common 
cause.  In  six  per 
cent,  of  women 
pregnancy  may 
be  expected  to 
be  prolonged  be- 
yond the  three- 
hundredth  day, 
and  for  e\'ery 
day  that  the 
fetus  is  retained 
in  the  womb  beyond  the  usual  time  there  is  an  increase  in  its  size 
and  weight  above  the  normal.  So  much  difficulty  and  danger 
may  be  experienced  from  this  cause  that  it  is  a  good  rule  in 
practice  to  allow  no  woman  to  exceed-  the  normal  duration  of 
pregnancy  by  more  than  two  weeks.  By  inducing  labor  at  that 
time  one  occasionally  interferes  unnecessarily,  but  he  often  avoids 
complications  and  difficulties  of  the  most  serious  nature. 

Oversize  and  advanced  age  of  one  or  both  parents  may  be  a 
cause  of  overgrowth  in  the  fetus — the  latter  usually  because  it 
predisposes  to  a  prolongation  of  pregnancy.  It  is  commonly 
asserted  that  the  size  of  children  increases  in  successive  pregnan- 
cies up  to  the  fourth  or  fifth,  and  then  remains  stationary  or  even 
decreases;  but  there  are  important  exceptions  to  this  rule.     The 


Fig.  429. — Overgrowth  of  head  obstructing  labor. 


ANOMALIES  IN  THE   FORCES   OF  LABOR. 


555 


writer  has  seen  the  tenth  child  vastly  exceed  in  size  the  nine  pre- 
ceding ;  it  weighed  1 5  pounds,  and  it  was  necessary  to  deliver 
it  by  Cesarean  section.  The  other  children  had  been  born  natu- 
rally through  a  flat  pelvis  with  a  conjugate  diameter  of  nine  centi- 


Fig.  430. — Dicephalus. 


Fig.  431. — -Dicephalus. 


Fig.    432. — Lymphangioma. 


Fig.  433-  — Craniopagus. 


Ischiopagus  parasiticus. 


meters.  The  increase  in  size  of  successive  children  must  be 
borne  in  mind  in  cases  of  contracted  pelvis.  The  first  two  or 
three  infants  may  be  delivered  spontaneously,  but  the  larger  size 
of  the  fourth  or  fifth  may  make  natural  delivery  impossible.^ 

Overgrowth  of  the  fetus  is  the  most  difficult  condition  in 
obstetric  practice  to  diagnosticate  with  precision.  A  careful  [xil- 
pation  of  the  head  and  body  and  an  attempt  to  push  the  former 

'  T,ehiriann  in  712  h\bors  through  198  contracted  pelves  found  increasing  diffi- 
culty in  delivery  with  each  succeeding  labor.  In  first  labors  50  per  cent,  ended  spon- 
taneously ;  in  second,  43.8  ;  in  fourth,  3S.4 ;  in  iifth,  33  j<3  ;  and  in  labors  after  the  fifth 
only  g.  8  per  cent.  ("Diss.  Inaug.,"  Berlin,  1891). 


556 


THE   PATHOLOGY   OF  LABOR. 


Fig.  435. — Prosopothoracopagus.        Pig.  436. — Xiphopagus.        Fig.  437. — Janiceps. 


Fig.  438. —  Dicephalus  :  neither  head  engaged. 

into  the  pelvic  inlet  may  give  one  an  approximate  idea  of  the- 
relative  size  of  fetal  body  and  pehic  canal,  and  the  methods  of 
antepartum  fetometry  already  described  may  enable  the  physician 


ANOMALIES  IN  THE  EORCES  OE  LABOR. 


557 


Fig.  439. — Hydrencephalocele  (anterior). 


Fig.   440. — .Sacral  teralumu  obslrucling  labor. 


558  THE   PATHOLOGY  OF  LABOR. 

to  estimate  the  size  of  the  fetal  head  accurately,  but,  as  a  matter 
of  fact,  the  large  size  of  the  fetus  is  usually  discovered  in  prac- 
tice only  after  prolonged  delay  when  attempts  at  artificial  delivery 
especially  by  version,  have  failed.  By  this  time  the  fetus  is  com- 
monly dead,  and  should  be  delivered  by  embryotomy.  But  the 
practitioner  must  be  on  his  guard  against  futile  attempts  to  de- 
liver an  infant  too  large,  even  when  mutilated,  to  pass  through 
the  pelvis.  The  writer  has  seen,  in  consultation  practice,  several 
maternal  deaths  due  to  this  cause. 

Premature  Ossification  of  Cranium  ;  Worniian  Bones  ;  ^  Large 
Heads  ;  Malformations  and  Tnmors  of  the  Fetus. — No  single  rule 


Fig.  441. — Myxoma  of  neck  Fig.    442. — Sacral    tumor    (Mutter 

.(Longaker).  Museum,  College  of  Physicians). 

of  treatment  can  be  laid  down  for  the  management  of  these  cases. 
Forceps,  version,  or  some  form,  of  embryotomy  is  usually  de- 
manded. Spontaneous  labor,  however,  is  possible  even  in  cases 
of  monstrous  bulk  in  which  delivery  through  the  birth-canal 
would  seem  out  of  the  question.  Thus,  in  double  monsters 
joined  loosely  by  the  front  or  back  (xiphopagus,  the  Siamese 
twins;  pygopagus,  the  Hungarian  sisters),  one  child  may  be  born 
by  the  head,  the  other  afterward  by  the  breech,  or  vice  versa.  In 
dicephali  one  head  may  be  pressed  into  the  neck  of  the  other  or 
may  rest  upon  the  iliac  bone  of  the  mother  until  the  first  head 
makes  its  escape  from  the  vulva.  Even  in  thoracopagus,  the 
commonest  double  monstrosity,  in  which  two  trunks  are  inti- 
mately joined  front  to  front,  spontaneous  labor  is  possible  by 
the  mechanism  shown  in  figure  445.     On  the   other  hand,  the 

1  Dr.  Grace  Peckam  ("New  York  Med.  Record,"  April  14,  1888)  has  reported 
three  still-births,  attributed  in  each  instance  to  the  development  of  Worniian  bones  in 
the  smaller  fontanel,  and  to  the  consequent  interference  with  overlapping  of  the  cra- 
nial bones  at  the  sutures.      This  observation  has  not  yet  been  verified  by  others. 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


559 


greatest  difficulty  may  be  encountered  in  labor,  and  a  Cesarean 
section  may  be  necessary.^ 


Fi.CT.  443- — Anasarca. 


Fig   444. -Mechanism  of  labor  with  Fig.  445-— Mechanism  oi  labor  in  thora- 

dicephalus  (Kustner).  copagus  (^Kustner). 

Fetal  tumors  ob.structino-  delivery  may  be  hydreiicephaloceles, 
lymphangiomata,  myxomata,  sacral  teratomata.  C)'stic  tumors 
should  be  punctured.     Solid  tumors  may  call  lor  version  or  for 

'There  are  two  recorded  deliveries  of  thoracopagi  by  Cesarean  section  (Hirst 
and  Piersol,  "  Human  Monstrosities"). 


560  THE  PATHOLOGY  OF  LABOR. 

embryotomy.  In  a  case  of  sacral  teratoma,  the  child  presenting 
by  the  umbilicus,  the  author  found  it  necessary  to  eviscerate  the 
infant  before  it  could  be  extracted.  The  tumor  has  been  ampu- 
tated, embryotomy  and  version  have  been  performed.  The  tumior 
not  infrequently  ruptures  and  often  the  labor  is  easy  because  the 
fetus  is  premature/  Craniotomy  may  be  required  in  monstrous 
enlargement  of  the  cephalic  extremity,  as  in  syncephalus  or  in 
diprosopus.  Decapitation  may  be  necessary  in  duphcity  of  the 
cephahc  extremity,  as  in  dicephalus  or  in  thoracopagus.  In 
JR-eina's  case  of  tricephalus  the  first  head  was  perforated  and  then 
amputated,  the  second  was  perforated,  crushed,  and  amputated, 
and  the  third  was  amputated. 

Diseases  mid  Deatli  of  the  Fetus. — All  diseases  of  the  fetus 
that  increase  its  bulk  may  obstruct  labor.  Cystic  tumors,  effu- 
sions in  the  serous  cavities,  anasarca,  an  enlarged  liver,  polycystic 
disease  of  the  kidneys,^  and  distended  bladder  from  atresia  of 
the  urethra^  are  examples.  Liquid  accumulations  should  be 
evacuated  by  puncture  or  b}^  incisions. 

HydroceplialiLS  is  the  most  important  of  the  diseases  increasing 
fetal  bulk.  It  is  not  very  rare,^  is  often  overlooked,  and  is  a 
frequent  cause  of  ruptured  uterus.  The  diagnosis  may  be  made 
by  a  vaginal  examination,  by  abdominal  palpation,  and  by  a  com- 
bined examination,  or,  if  necessary,  by  anesthetizing  the  woman, 
introducing  the  whole  hand  into  the  vagina,  and  thoroughly 
palpating  the  enlarged  head  resting  above  the  pelvic  brim.  The 
gaping  fontanel,  the  great  width  of  the  sutures,  the  fluctua- 
tion within  the  cranium,  the  large  size  of  the  head  appreciated  by 
bimanual  examination,  and  possibly  the  abnormal  mobility  of  the 
cranial  bones,  and  in  some  cases  their  extreme  tenuity,  indicate 
the  condition.  Hydrocephalus  is  very  often  overlooked  in  practice 
as  the  result  usually  of  a  careless,  superficial  examination.  A 
painstaking  and  methodical  investigation  of  a  suspected  case 
should  obviate  this  error.  There  are  cases,  however,  in  which  there 
is  no  increased  width  of  the  sutures,  no  enlargement  of  the  fon- 
tanels, and  such  slight  enlargement  of  the  head  that  it  can  not 
be  appreciated;  and  yet  the  fluid  contents  of  the  cranium  pre- 
vent compression  of  the  skull  and  make  the  engagement  of  the 

^  For  interesting  statistics  of  this  condition  see  UthmoHer,  "  Ueber  Geburten  be! 
steisstumoren,"  "  Monatschr.  f.  Geb.  u    Gyn.,"  Dec,  1903.      Of  the  collected  cases 
126  have  been  girls,  60  boys.      The  frequency  is  reckoned  at  I-34,  582  births. 
2  Fussell,  "Med.  News,"  Philadelphia,  1891,  p.  40. 

^  Schwyzer  ("  Archiv  f.  Gyn.,"  Bd.  xliii)  has  collected  13  cases  of  dilatation  of 
the  fetal  bladder  from  atresia  of  the  urethra,  stenosis  of  the  urethra,  and  obstruction 
of  the  urethra  by  a  valve-like  formation  of  mucous  membrane.  Miiller  reports  a  case 
and  quotes  another  ("Archiv  f.  Gyn."  Bd.  xlvii,  H.  l). 

*  Schuchard  found  it  sixteen  times  in  12,055  births  ;  Lachapelle  and  Duges, 
fifteen  times  in  43,555  ;  Merriman,  once  in  900.  In  159  cases  there  were  38 
maternal  deaths,  20  of  which  were  from  rupture  of  the  uterus. 


ANOMALIES  IN  THE   FORCES   OF  LABOR. 


561 


head  impossible.  The  writer  has  seen  such  cases  (see  Fig.  446). 
Hydrocephalus  should  always  be  suspected  if  the  head  in  labor 
remains  above  the  brim,  although  the  pelvis  is  normal  in  size  and 
no  good  reason  can  be  found  for  the  failure  of  engagement. 

The  treatment  of  labor  obstructed  by  hydrocephalus  is  punc- 
ture of  the  cranium  with  a  perforator  and  evacuation  of  its  fluid 
contents.  A  child  with  this  disease  deserves  no  consideration. 
After  the  reduction  in  the  size  of  the  head  the  labor  may  be  left 
to  the  natural  forces.  If  these  prove  insufficient,  a  cranioclast 
may  be  fastened  to  the  skull  and- the  child  be  extracted  artificially. 
A  cardinal  rule  in  the  treatment  of  these  cases  is  to  avoid  at- 
tempts to  deliver  with  forceps — a  common  error  in  practice,  and 
one  that  has  cost  many  a  woman  her  life  from  ruptured   uterus, 


^■i|kJ|£|r''\v 

^ 

■Kv . 

^1 

W  K 

fl 

■  / 

fl 

^H 

'v.--*^H 

^^^^^k 

J^^H 

Fig.  446. — Hydrocephalus:  very  Fig.  447.— Hydrocephalus  :    enorriious 

moderatedisientionof  the  cranium,  but  collection     of     fluid    (author's     collection: 

sufficient  to  prove  an  insuperable  ob-  specimen  presented  by  Dr.  Alex.    Fulton). 
Stack  in  labor. 


from  deep  tears  when  the  in.strument  slips,  as  it  will,  and  from 
extensive  sloughs  after  delivery. 

If  the  pelvic  extremity  of  the  hydrocephalic  fetus  presents. — 

as  it  docs  in  almost  a  third  of  all  cases, — and  if  the  head  remains 

inaccessible  above  the  superior  strait,  so  that  it  can  not  easily  be 

punctured,  the  spinal  canal  may  be  opened,  a  catheter  be  passed 

-,6 


562 


THE  PATHOLOGY  OF  LABOR. 


through  it  into  the  cranial  cavity  (Van  Huevel's  method),  and 
the  fluid  thus  be  evacuated  (Fig.  448).  Usually,  however,  there 
is  no  special  difhcuhy  or  danger  in  the  delivery  of  the  after- 
coming  head  of  a  hydrocephalic  infant.  The  force  required  for 
its  extraction  not  infrequently  ruptures  the  walls  of  the  ventricles 
and  converts  the  case  into  one  of  external  hydrocephalus,  or 
possibly  drives  the  fluid  out  of  the  foramen  magnum  into  the 
tissues  of  the  neck  and  back,  so  reducing  the  bulk  of  the  head 
as    to   permit   its   extraction.      At   any  rate,   the    condition  can 


Fig.  448. — Tapping  a  hydrocephalus  through  the  spinal  canal  (Varnier). 


scarcely  escape  the  notice  of  the  medical  attendant,  and  a  diag- 
nosis is  made  before  the  lower  uterine  segment  is  dangerously 
stretched  or  ruptured.  The  head  may  be  punctured  through  the 
roof  of  the  mouth,  through  the  foramen  magnum,  or  behind  the  ear. 


ANOMALIES  IN  THE  FORCES  OF  LABOR. 


563 


The  difficulty  in  the  dehvery  of  a  hydrocephahc  fetus  is  not  in 
direct  proportion  to  the  quantity  of  fluid  in  the  ventricles  and 
the  size  of  the  head.  In  cases  of  extreme  distention,  the  cranial 
vault  is  likely  to  rupture,  while  in  moderate  grades  of  hydro- 
cephalus the  quantity  of  brain-substance  surrounding  the  ven- 
tricles and  the  strength  of  the  brain-membranes  forbid  this 
means  of  spontaneous  delivery. 

Malprescntations  and  faulty  positions  include  shoulder,  face, 
brow,  deviated  vertex,  and   compound  presentations.      All  but 


Fig.  449. — Compound  presentation  :  liead  and  hand.  Braun's  section  of  a 
multipara  who  committed  suicide  by  hanging  in  the  last  month  of  pregnancy  :  a. 
Venous  sinuses;  b,  uterovesical  rellection  of  peritoneum;  <-,  symjihysis  pubis;  </, 
bladder;  e,  vagina;  /",  first  lumbar  vertebra  ;  g,  promontory  of  sacrum;  li,  rectum; 
z,  cervix  ;  j,  pouch  of  Douglas. 


the  last  are  considered  elsewhere.  By  compound  presentation 
is  meant  the  presentation  of  two  or  more  parts  at  tlic  same  time, 
as  a  head  and  a   hand,  a  licad  and  a  foot,  a  hand   and   a  foot. 


5 64  THE  PA THOL OGY  OF  LABOR. 

nuchal  position  of  the  arm,  or  the  head  and   all  four  extrem- 
ities. 

A  compound  presentation  is  met  with  about  once  in  250 
labors.  It  is  usually  a  head  and  a  hand.  The  following  table  is 
furnished  by  Pernice  from  2891  births  in  the  clinic  at  Halle  : 

Hand  and  head, 26 

Arm  and  head, 8, 

Hand  and  umbilical  cord, _  .  5 

Both  hands, ■  4 

Foot  and  hand, 2    , 

Two  hands,  umbilical  cord,  and  foot, I 

Face,  hand,  and  cord, I 

Kietz  found  in  7555   labors  the  foot  and  head  presenting  in  23.1 
The  cause  of  compound  presentations  is  usually  a  lack  of 


Fig.  450. — Compound  presentation  :  head  and  foot  f author's  case). 


conformity  in  the  presenting  part  with  the  pelvic  inlet,  as  in  mal- 
position of  the  fetus,  a  head  of  abnormal  size,  a  displaced  uterus, 
twins,  hydramnios,  contracted  pehas,  and  anomalous  shape  of 
the  uterus. 

In  the  treatment  of  compound  presentations  before  rupture  of 
the  membranes  an  attempt  should  be  made  to  overcome  the 
difficulty  by  postural  treatment.  The  woman  should  be  placed 
on  that  side  opposite  the  prolapsed  extremity.     After  rupture  of 

^  "Diss.  Inaug.,"  Berlin,  1S90, 


ANOMALIES  IN  THE  FORCES  OF  LABOR.  565 

the  membranes  an  attempt  should  be  made  to  dislodge  the  pro- 
lapsed extremity  and  to  restore  it  to  its  natural  position.  Version 
may,  however,  be  required  if  this  attempt  fails,  or  even  crani- 
otomy if  the  child  is  dead.  If  the  head  and  extremities  present, 
and  if  the  former  is  engaged,  it  is  usually  best  to  apply  forceps 
and  to  disregard  the  prolapsed  extremities.  In  the  case  of 
nuchal  position  of  the  arm,  an  effort  should  be  made  to  dislodge 
the  latter,  but  it  may  be  necessary  to  fracture  it  before  the 
delivery  of  the  child  can  be  secured. 


Fig.  451. — Twins;  breech  and  face  presentations. 

Multiple  BivtJis. — Twin  labors  are  usuallx'  easy  and  uncom- 
plicated (75  per  cent.),  but  complications  are  more  frequent 
than  in  single  labors.  Malprescntations  are  common.  The 
following  table  from  Spiegelberg,  based  on  1138  labors,  gives 
the    combined  presentations    in    the   order   of  their  frequency : 

Both  heads  presenting, 40        ptr  cent. 

Head  and  lireech, 31.70    "      '■ 

Both  pelvic  presentations, S.60    "      " 

Head  and  transverse,       6.18    "      " 

Breech  and  transverse, 4.  I4    "      " 

Both  transverse, 35    "      " 


566 


THE  PATHOLOGY  OF  LABOR. 


It  may  be  noted  that  a  transverse  position  is  found  in  10.67  per 
cent,  of  cases.  Mechanical  difficulties  in  labor  are  frequent :  the 
uterine  muscle  is  usually  weakened  by  overstretching,  and  there 
may  be  trouble  in  the  third  stage  of  labor  in  the  delivery  of  the 
placenta.  Some  form  of  operative  interference  is  demanded  in 
about  25  per  cent,  of  all  cases. 


Fig.  452. — Impaction  of  heads  in  twin  labor. 


Locking  of  heads  in  twin  labor. 


In  the  majority  of  cases  (79  per  cent.)  the  interval  between 
the  delivery  of  twins  is  less  than  an  hour.^  A  longer  delay 
than  this  indicates  the  likelihood  of  some  obstruction  to  the  birth 
of  the  second  infant  or  a  failure  of  expulsive  forces. 

1  In  the  "  Semaine  Med.,"  I904,  ii,  27,  Paulin  reports  an  interval  of  twenty-one 
days  between  the  birth  of  twins.  It  was  subsequently  discovered  that  there  was  a 
uterus  bicornis  unicollis.  This  is  probably  the  explanation  of  the  cases  occasionally 
reported  of  the  birth  of  children  weeks  and  even  months  apart. 


AXOMALIES  IN  THE  FORCES  OF  LABOR. 


567 


Serious  difficulty  in  twin  labors  may  arise  in  one  of  three  ways: 
Both  heads  present  at  once,  one  a  little  in  advance  of  the  other, 
the  second  impacted  in  the  neck  of  the  first  (Fig.  452);  the  first 
child  descends  by  the  breech,  and  the  head  of  the  second  child  is 
caught  by  the  chin  of  the  first  and  pushed  into  the  pelvis  (Fig. 
453) ;  one  child  sits  astride  of  the  other,  which  is  transverse.  If 
both  children  should  be  found  attempting  to  engage  by  the  head 
in  the  superior  strait  at  one  time,  one  child  should  be  retarded 
while  the  other  is  artificially  extracted.  If  this  is  impossible,  the 
first  head  should  be  extracted  by  forceps,  the  second  be  treated 
in  like  manner,  and  then  the  trunks  should  be  delivered  one  after 
the  other.  Embryotomy  is  a  last  resort,  but  is  scarcely  ever 
necessary. 

A  coiling  of  the  cords  (Fig.  454)  and  their  entanglement  may 
be  a  source  of  difficulty  and  delay  in 
unioval  twins.  It  may  be  necessary 
to  cut  one  or  both  cords  between 
ligatures  before  the  children  can  be 
delivered. 

In  case  one  child  presents  by  the 
head  and  the  other  by  the  feet,  both 
may  come  down  together,  and  the 
two  heads  become  locked  in  the  pel- 
vic entrance  and  canal.  An  effort 
may  be  made  to  push  back  the  child 
presenting  by  the  head.  If  this  suc- 
ceeds, the  child  presenting  by  the 
breech  should  be  extracted  immedi- 
ately, for  it  is  in  imminent  danger 
from  asphyxia.  It  may  be  possible 
with  force-ps  to  pull  the  child  pre- 
senting by  the  head  past  the  body  of 
its  fellow  presenting  by  the  breech. 
Failing  in  these  attempts,  the  child 
presenting  by  the  breech  will  almost 
surely  have  died,  and  there  will  be  no 
pulsation  in  its  cord.      It  should  then 

be  decapitated,  whereupon  the  infant  presenting  by  the  head  can 
be  extracted  without  difficulty  by  forceps. 

In  any  case  of  twin  labor,  as  soon  as  the  first  child  is  born, 
and  the  cord,  ligated  with  a  double  ligature,  is  cut,  the  attendant 
should  immediately  investigate  the  position  and  presentation  of 
the  second  child.  A  neglect  of  this  rule  leads  very  often  to  the 
impaction  of  an  unrecognized  shoulder  presentation  in  the  second 
child,  and  its  consequent  death.  If  an  abnormality  is  discovered 
in  the  presentation  of  the  second  child,  it  should  at  once  be  cor- 


Fig.      454. — Entanglement     of 
cords  in  twins   (Winckel). 


568 


THE   PATHOLOGY  OF  LABOR. 


rected.  Then,  after  waiting  perhaps  half  an  hour,  the  amniotic 
sac  should  be  ruptured,  and  ergot  should  be  administered  in  a  full 
dose  to  secure  a  speedy  delivery,  or,  if  the  stomach  will  not  retain 
it,  ergotin  should  be  given  hypodermically,  for,  the  birth-canal 
having  been  dilated  thoroughly,  there  is  no  obstacle  to  the  birth 
of  the  second  infant  in  twin  labors,  and  consequently  no  objection 
to  the  employment  of  ergot,  which  not  only  hastens  the  con- 
clusion of  labor,  but  promotes  subsequent  contraction  of  the 
much-distended  uterus,  and  so  prevents  postpartum  hemorrhage. 
As  a  further  precaution  against  this  accident  which  is  always 


Fig.  455- — Twins,  head  and  breech  (modified  from  Hunter). 


threatened  in   twin   labors,  the  fundus  should  be  kneaded  and 
compressed  by  the  nurse  for  an  hour  or  two  after  birth. 

There  may  be  difficulty  in  the  delivery  of  the  placenta;  in  twin 
labors.  Commonly  the  children  are  born  first  and  the  placentae 
afterward.  Their  bulk  may  make  expression  difficult,  and  it  is 
often  necessary  to  make  some  traction  upon  the  cords — first  upon 


ANOMALIES  IN  THE  FORCES  OF  LABOR.  569 

one  and  then  upon  the  other — to  determine  which  placenta  will 
come  first  and  to  assist  in  its  expulsion.  Occasionally  one  and 
rarely  both  placenta  may  be  expelled  after  the  birth  of  the  first 
child.  In  a  case  of  the  writer's  the  placenta  of  the  first  child, 
prolapsing  in  front  of  the  second,  necessitated  a  difficult  forceps 
operation  for  the  extraction  of  the  second.  On  account  of  the 
frequent  and  extensive  anastomoses  between  the  vessels  of  the 
placentae  in  unioval  twins  it  is  a  necessary  precaution  to  tie  the 
cord  of  the  first  child  with  a  double  ligature  and  to  cut  it  between 
the  ligatures  ;  otherwise  the  second  infant  might  bleed  to  death. 

The  prognosis  of  twin  labors  is  always  doubtful.  There  are 
so  many  possible  dangers  for  both  mother  and  children  that 
multiple  labors  must  be  regarded  as  distinctly  pathological. 
Albuminuria  in  the  mother  is  the  rule  in  multiple  pregnancies, 
and  eclampsia  is  ten  times  more  frequent  than  in  single  births.  ^ 
There  is  a  disposition  to  inertia  uteri  during  and  after  birth  from 
distention  of  the  cavity,  and  consequently  a  likelihood  of  post- 
partum hemorrhage.  Some  operative  interference  or  intra- 
uterine manipulation  is  called  for  in  about  twenty-five  per  cent, 
of  cases,  and  this,  in  addition  to  the  frequency  of  kidney  insuf- 
ficiency, predisposes  to  sepsis.  Finally,  there  may  be  insuperable 
obstruction  in  labor  if  locked  twins  are  not  managed  properly, 
and  the  woman  may  die  of  ruptured  uterus  or  of  exhaustion. 
The  maternal  mortality  in  the  Budapest  Maternity  was  four 
times  as  great  as  in  the  single  births,  and  Kleinwachter's  statis- 
tics give  a  mortality  of  thirteen  per  cent.  For  the  children  there 
is  greater  danger  than  for  the  mother.  Twin  pregnancy  is 
almost  always  prematurely  interrupted,  and  even  if  it  is  not  the 
children  are,  as  a  rule,  under  the  normal  size  and  weight.  There 
is  always  the  possibility  that  the  development  of  one  child  at 
least  will  be  seriously  interfered  with  by  the  lack  of  room  in  the 
uterine  cavity.  Hydramnios  of  one  sac  and  oligohydramnios  of 
the  other  are  not  uncommon.  In  labor  there  are  frequently 
complications  from  malposition,  operative  interference,  entangle- 
ment of  or  pressure  upon  the  cords,  and  more  rarely  the  engage- 
ment of  both  bodies  at  once  in  the  pelvic  canal.  In  Klein- 
wachter^s  and  Kezmarszky's  statistics  the  fetal  mortality  was 
nearly  forty  per  cent.  Of  thirty-eight  children  in  cases  of  locked 
twins,  only  six  survived, — a  mortality  of  eighty -four  per  cent. 

Cases  are  on  record  in  which  an  extra-uterine  fetus  has 
obstructed  the  delivery  of  the  intra-uterine  twin.  It  has  been 
necessary  to  make  a  vaginal  incision  through  which  the  former 
was  extracted  before  the  latter  could  be  born. 

Death  of  the  fetus  during  or  before  labor,  followed  by  rigor 

^  Of  627  cases  of  eclampsia,  69  were  multiple  pregnancies  (Winckel). 


570 


THE  PATHOLOGY  OF  LABOR. 


mortis,  has  proven  a  source  of  obstruction  in  labor  by  the  rigidity 
of  the  child  and  the  consequent  interference  with  the  normal 
mechanism  of  its  delivery,  especially  of  the  shoulders  and  trunk.  ^ 
Ankylosis  of  the  large  joints  of  the  extremities  may  have  the 
same  effect  to  a  less  degree. 

Labor  Complicated  by  Abnormalities  in  the  Fetal  Appendages. — 
Membranes. — If  the  membranes  are  too  thin,  they  may  rupture 
prematurely,  and  thus  give  rise  to  what  is  called  a  "dry  labor," 
in  which  the  birth-canal  must  be  dilated  by  the  hard,  unyielding 
presenting  part  instead  of  by  the  bag  of  waters.  Such  labors  are 
longer  and  more  painful  than  the  average,  and  there  is  a  greater 
likelihood  of  lacerations  in  the  cervix  and  a  more  frequent  demand 
for  an  artificial  termination  with  forceps.  If  the  membranes  are  too 
thick,  they  rupture  late,  being  preserved  perhaps  until  the  child's 
head  presents  at  the  vulvar  orifice,  or  even  until  the  complete 
escape  of  the  head  from  the  mother's  body.  In  these  cases  the 
head  and  face  are  covered  by  the  membranes  as  though  by  a  veil, 
and  care  must  be  taken  to  free  the  mouth  and  nose  quickly,  that 
respiration  may  be  instituted  without  interference.  The  mem- 
branes thus  covering  the  head  and  face  are  spoken  of  as  a  "  caul." . 
It  is  possible  for  the  whole  ovum  to  be  extruded  unbroken  at 
term.  The  writer  has  seen  this  occur  as  late  as  the  seventh 
month,  and  it  is  actually  recorded  at  the  full  period  of  gestation. 

Difficulties  in  labor  may  be  encountered  in  consequence  of  an 
abnormality  in  the  quantity  of  liquor  amnii.  If  there  is  too  little, 
the  labor  has  the  same  clinical  features  as  though  there  had  been 
a  premature  rupture  of  the  membranes.  If  there  is  too  much 
liquor  amnii,  there  may  be  inertia  as  the  result  of  overstretching 
of  the  uterine  muscle-fibers. 

Umbilical  Cord. — If  the  umbilical  cord  is  too  short,  it  may 
cause  premature  detachment  of  the  placenta  or  may  prevent  the 
advance  of  the  child.  The  diagjtosis  of  a  short  cord  in  labor  is 
always  difficult.  It  may  be  suspected,  however,  if  there  is 
exaggerated  pain  at  the  placental  site,  marked  recession  of  the 
head  after  each  pain,  and  an  obvious  retardation  of  labor  without 
other  ascertainable  cause.  Forceps  should  be  applied  in  such  a 
case  if  the  presentation  is  cephalic.  If  the  cord  is  too  long,  it 
may  possibly  prolapse  should  there  be  other  conditions  in  the 
labor  favorable  to  such  an  accident ;  or  it  may  be  coiled  about 
the  child's  neck,  trunk,  or  extremities,  and  may  consequently  be 
fatally  compressed  during  labor  (Fig.  456). 

Obstruction  of  a  mechanical  character  in  labor  on  the  part  of 

^  Feis,  "  Ueber  intrauterine  Leichenstarre,"  "Archiv  fiir  Gynakologie,"  Bd. 
xlvi,  H.  2. 


ANOMALIES  IN   THE   FORCES   OE  LABOR. 


571 


the  placenta  is  seen  only  in  placenta  praevia  and  in  prolapse  of  the 
placenta.  The  placenta  may  be  adherent  as  the  result  of  syphil- 
itic or  other  inflammation  of  the  endometrium  during  pregnancy, 
and,  becoming  partially  detached  in  the  third  stage,  may  cause 
alarming  hemorrhage.     It  is  often  simply  retained  in  the  lower 


Fig.  456.  —  Placenta  praevia:  umbilical  cord,   caught  in  the   axilla,    encircling    the 
shoulder  and  prolapsed  (Hunter). 


uterine  segment  or  in  the  vagina,  whence  it  may  be  expressed 
by  the  proper  application  of  Crede's  method.  In  some  cases 
atmospheric  pressure  obstructs  the  deHvery  of  a  retained  placenta 
so  effectually  that  it  is  necessary  to  hook  one's  finger  over  the  edge 
of  it,  to  allow  the  access  of  air  behind  it,  before  its  expression  is 
possible.     Retention  of  the  placenta  may  be  due  to  its  great  bulk, 


572  THE   PATHOLOGY   OF  LABOR. 

as  in  twin  placentas,  or  to  tumors  increasing  in  size.     In  such  cases 
it  may  be  necessary  to  extract  the  placenta  manually. 

LABOR  COMPLICATED  BY  ACCIDENTS  AND  DISEASES. 

Hemorrhage. — One  of  the  gravest  and,  unfortunately,  one  of 
the  commonest  accidents  during  and  directly  after  labor  is  hemor- 
rhage. The  causes  of  hemorrhage  during  the  first  and  second 
stages  of  labor  are  placenta  prsevia,  premature  separation  of  a 
normally  situated  placenta,  rupture  of  the  uterus,  lacerations 
along  the  lower  birth-canal,  and  rupture  of  a  blood-vessel  or  of 
a  hematoma.  The  causes  of  hemorrhage  during  the  third  stage 
of  labor  and  directly  afterward  are  relaxation  of  the  uterus,  lacera- 
tions of  the  birth-canal,  rupture  of  blood-vessels  or  of  hema- 
tomata. 

Placenta  Praevia. — By  placenta  previa  is  meant  the  attach- 
ment of  the  placenta  to  the  lower  uterine  segment.  In  some 
varieties  of  the  condition  the  placenta  presents  itself  first  to  the 
examining  finger,  and  may  even  emerge  before  or  in  front  of  the 
child  ;  hence  the  name. 

History. — Early  writers  (Guillemau  and  Mauriceau,  1609— 
1668)  recognized  placenta  praevia,  but  they  explained  it  as  an 
accidental  prolapse  of  the  placenta.  Portal  (1685)  described  it 
more  correctly,  though  indistinctly.  Schaller  (1709)  demon- 
strated the  condition  in  the  dissection  of  a  body.  From  Levret's 
time  placenta  praevia  was  well  understood.  Rigby  (1789)  defines 
it  as  the  attachm.ent  of  the  placenta  to  that  part  of  the  womb 
which  always  dilates  as  labor  advances — a  definition  that  is 
strictly  accurate  to-day.  It  is  to  Rigby,  too,  that  we  owe  the 
term  "unavoidable  hemorrhage  "  to  describe  the  hemorrhage  of 
placenta  praevia,  as  opposed  to  the  "accidental  hemorrhage" 
from  premature  detachm.ent  of  a  normally  situated  placenta. 

Frequency. — Placenta  praevia  varies  in  the  frequency  of  its 
occurrence  in  different  localities  and  at  different  times,  as  the 
following  table  demonstrates  : 

Cases   of 
Number  of      Placenta 
Reporter.  Labors.  Pr.-evia.      Proportion. 

C.  V.   Braun 7,853  ^5  1-522 

Hugenberger 8,036  42  I-I9I 

Lomer. 6,862  136  1-50 

Winckel    (1873-78) 6,324  7  1-903 

Winckel    (1879-87) 8,500  30  I-283 

Muller 876,432  813  I-1078 

Lusk 1,550  o  0-0 

Schwarz 5''9,32S  332  1-1564 

Midwives'  report  in  Saxony  (1878)     .    .119-553  78  I-IS32 

The  frequency  of  placenta  prsevia  may  be  estimated  at  about 
I  in  1200  labors.     If  the  situation  of  the  placenta  were  investi- 


LABOR    COMPLICATED   BY  ACCIDENTS  AND  DISEASES.    573 


gated  by  a  careful   examination  of  the   rent  in  the  membranes 
after  every  labor,  placenta  praevia   would   be   found   quite   fre- 


Fig   457- — Central  placenta  praevia,  the  os  partly  dilated  (Hunter). 

quently.  In  my  experience  it  has  occurred  about  once  in  300 
labors  ;  but  in  only  a  quarter  of  the  cases  was  the  condition 
manifested  before  and  during  labor  by  its  most  characteristic 
symptom,  hemorrhage. 

Etiology. — A  perfectly  satisfactory  e.xjjlanation  for  the  occur- 
rence of  placenta  praevia  has  not  yet  been  found.  Clinical  ob- 
servation shows  that  any  chronic  indammation  or  congestion  of 


574  ^^^   PATHOLOGY  OF  LABOR. 

the  womb  predisposes  to  it.  Hence  placenta  previa  is  three  to 
six  times  more  common  in  multiparae  than  in  primiparae,  and  is 
more  often  met  with  in  the  working  classes.  Uterine  myomata 
and  carcinoma  of  the  cen^ix  are  predisposing  causes,  on  account, 
no  doubt,  of  the  endometritis  that  accompanies  them.  Ingelby 
reports  two  cases  of  abnormally  low  situation  of  the  tubal  orifices, 
in  one  of  which  placenta  previa  occurred  three  times  ;  in  the 
other,  ten.  Multiple  pregnancies,  according  to  ^^lnckel,  furnish 
four  times  as  many  cases  of  placenta  prsevia  as  do  single  preg- 
nancies, and  a  woman  beginning  to  bear  children  late  in  life  is 
liable  to  placenta  prsevia  in  subsequent  pregnancies.  Uterine 
malformations  are  apparent!}'  a  predisposing  cause.  A  case  is 
reported  by  Schwarz  of  uterus  bicornis  in  which  placenta  prsevia 
recurred  three  times. 

Hofmeier  and  Kaltenbach^  furnish  the  best  explanation  for 
the  abnormal  situation  of  the  placenta.  These  observers  have 
demonstrated,  by  the  examination  of  young  ova,  that  the  chorion 
villi  in  the  lower  pole  of  the  o\-um  may  de\-elop  in  an  hyper- 
trophied  decidua  reflexa,  thus  carr}'ing  the  placenta  down  to  and 
across  the  internal  os.  At  first  an  adhesion  between  the  decidua 
vera  and  the  reflexa  is  prevented  by  catarrhal  discharge,  but  as 
the  ovum  develops  the  reflexa  ma}'  adhere  to  the  vera,  thus 
fixing  the  placenta  in  its  abnormal  situation,  permitting  its  con- 
tinued growth,  and  giving  rise  to  an  apparent  hypertrophy  of 
the  decidua  serotina.  Gottschalk's  ^  observation  of  a  young 
o\'um  imbedded  at  the  edge  of  the  internal  os  demonstrates  that 
an  abnormally  low  attachment  of  the  o\'um  in  the  uterine  cavity 
may  be  accountable  for  placenta  prsevia. 

Varieties. — Four  divisions  are  made  of  cases  of  placenta  previa 
— central,  partial,  marginal,  and  lateral.  In  the  first  the  center 
of  the  placenta  lies  over  the  internal  os  ;  in  the  second  the 
greater  mass  of  the  placenta,  lies  upon  one  side  of  the  lower 
uterine  segment,  usually  the  right  (56:37,  ^liiller),  though  the 
internal  os  is  completely  covered  by  it ;  in  the  third  a  margin  of 
the  placenta  projects  over  the  internal  os  ;  in  the  fourth  the 
placenta  is  situated  upon  one  side  of  the  lower  uterine  segment 
and  only  the  edge  of  it  projects  into  the  cer\acal  canal,  if  it 
does  so  at  all,  when  the  os  is  fully  dilated.  This  classification  is 
justified  upon  clinical  grounds.  In  central  and  partial  placenta 
praevia  the  hemorrhage  begins  earh-  in  pregnancy,  is  profuse  and 
frequently  repeated,  and  in  labor  is  more  dangerous  than  is  the 
hemorrhage  of  the  lateral  variet}-.  There  is  an  added  difficulty, 
too,  on  account  of  the  obstruction  offered  by  the  placenta, 
stretched  across  the  internal  os,  to  the  spontaneous  descent  of  the 

^  "  Lehrbuch  der  Geburtshulfe." 

2  "  Verhandl.  d.  deutsch.  Gesellsch.  f.  Gynak.,"  Bd.  vii,  1S97,  S.  289. 


LABOR    COMPLICATED   BY  ACCIDENTS  AND  DISEASES.    5/5 

child,  or  to  the  physician's  efforts  to  reach  and  extract  it.  In 
lateral  placenta  previa  hemorrhage  usually  does  not  occur  till 
labor  is  well  advanced,  and  often  does  not  appear  at  all.  Lateral 
and  marginal  placenta  praevia  are  the  commonest  varieties.  In 
270  cases  the  placenta  was  marginal  and  lateral  217  times  ;  cen- 
tral and  partial  53  times  (Winckelj.  Strictly  speaking,  central 
placenta  preevia  is  very  rare.  There  is  almost  invariably  more 
of  the  placenta  on  one  side  of  the  internal  os. 


B  Fundal. 


Fig.  45^- — Varieties  of  placenta  praevia:  in  A  there  are  seen  the  normal,  lateral, 
and  marginal  implantation  ;  in  li  there  are  represented  the  implantation  of  the  pla- 
centa at  the  fundus,  which  is  rare,  and  implantation  over  the  internal  os  ;  in  C  lateral 
implantation  and  that  of  a  cotyledon  immediately  over  the  internal  os ;  and  in  D 
partial  implantation  (Dickinson). 


Clinical  History. — A  woman  with  placenta  prai\'ia  ma}'  begin 
to  bleed  as  earh'  in  pregnane}'  as  the  second  month,  but  the  first 
hemorrhage  usually  occurs  in  the  last  trimester.  There  is  a  sudden 
gush  of  blood,  often  without  apparent  cause  and  without  pain. 
The  bleeding  commonly  recurs  in  increasing  amounts  and  at  de- 
creasing intervals  as  pregnane}^  advances.  In  very  rare  cases 
the  blood  leaks  away  continuously  (stillicidium),  though  this  is 
more  characteristic  of  the  premature  separation  of  a  normally 
situated  placenta.  The  cause  of  the  hemorrhage  during  preg- 
nancy is  the  impact  of  the  embryo  and  fetus  upon  the  placenta, 


5/6  THE    PATHOLOGY  OF  LABOR. 

the  pressure  of  the  ovum  upon  the  lower  uterine  segment,  and 
the  imperfect  attachment  of  the  placenta  in  certain  areas  to  the 
uterine  wall.  A  prediction  of  the  amount  of  bleeding  in  labor 
can  not  always  be  made  by  the  amount  of  blood  lost  or  the  fre- 
quency of  the  hemorrhages  in  pregnancy.  The  first  hemorrhage 
may  occur  in  labor,  which  may  be  ushered  in  by  a  tremendous 
outpour  of  blood,  even  in  lateral  placenta  prsevia.  Ordinarily, 
however,  the  greater  the  bleeding  during  pregnancy,  the  more 
likelihood  is  there  of  serious  hemorrhage  in  labor.  The  bleed- 
ing in  labor  is  easily  explained.  The  placenta  is  attached  in  that 
portion  of  the  uterine  cavity  which  must  be  dilated  to  allow  the 
advance  of  the  presenting  part.  The  stretching  of  the  uterine 
walls  expands  the  area  of  the  placental  site,  and  necessarily  de- 
taches the  placenta,  while  the  reversal  of  the  ordinary  mechanism, 
of  placental  detachment  keeps  the  gaping  mouths  of  the  torn 
uteroplacental  vessels  wide  open,  and  allows  the  blood  to  pour 
from  them  till  the  hemorrhage  is  checked  by  syncope,  by  throm- 
bosis, by  the  pressure  of  the  presenting  part,  or  by  a  vaginal 
•tampon.  The  source  of  the  bleeding  in  rare  cases  is  a  rupture 
of  the  circular  sinus  of  the  placenta,  a  laceration  of  the  fetal 
vessels  or  of  the  cervix. 

The  bleeding  is  usually  most  profuse  just  as  the  uterine  con- 
traction passes  off.  During  the  height  of  the  pains  it  may  cease 
altogether,  from  the  pressure  of  the  presenting  part  or  of  the 
intra-uterine  contents  upon  the  placental  site. 

As  the  placenta  occupies  a  portion  of  the  space  in  the  lower 
uterine  segment  and  may  prevent  the  descent  of  the  presenting 
part,  abnormalities  in  the  presentation  and  position  of  the  fetus  are 
common.  Transverse  and  oblique  positions  are  ten  times,  breech 
presentations  four  times,  more  frequent  than  in  normal  labors. 

In  the  first  stage  of  labor,  inertia  uteri  is  common,  partly  be- 
cause the  cervix  is  not  pressed  upon  and  reflex  irritation  is  absent, 
partly  on  account  of  the  loss  of  blood. 

The  OS  is  usually  patulous,  ev^en  before  labor  begins,  and  the 
cervical  canal  is  easily  dilated.  Occasionally,  however  (twelve 
per  cent.),  the  os  is  contracted  and  the  cervix  rigid. 

The  insertion  of  the  cord  is  often  marginal  or  velamentous, 
and  prolapse  of  the  cord  is  common. 

The  placenta  is  often  anomalous  in  shape,  size,  thickness,  and 
weight.  There  is  frequently  a  placenta  succenturiata.  As  the 
OS  dilates  the  placenta  may  be  torn  and  thus  separated  into  two 
parts.  An  adherent  placenta  may  be  expected  in  more  than  a 
third  of  the  cases  (Miiller,  thirty-nine  per  cent.). 

After  labor  there  is  a  tendency  to  inertia,  and  consequently 
to  postpartum  hemorrhage,  and  there  is  an  extraordinary  liability 
to  septic  infection. 


LABOR    COMPLICATED   BY  ACCIDENTS  AND   DISEASES.     5// 

Placenta  prasvia,  as  a  complication  in  labor,  would  be  much 
more  common  than  it  is  if  it  did  not  so  often  interrupt  pregnancy. 
The  frequency  of  abortion  and  miscarriage  is  placed  in  different 
statistics  at  forty  to  sixty  per  cent. 

In  quite  a  large  proportion  of  cases  placenta  praevia  would 
be  unrecognized  in  labor  without  a  careful  examination  of  the 
membranes  and  placenta  afterward.  Even  in  the  marginal  variety 
the  presenting  part,  unobstructed,  may  descend  quickly,  exerting 
such  pressure  upon  the  placental  site  that  bleeding  does  not  occur. 

Symptoms  and  Diagnosis. — Repeated  hemorrhages  during  the 
latter  part  of  pregnancy  make  the  diagnosis  of  placenta  preevia 
almost  certain.  On  digital  examination  the  cervix  is  found 
enlarged  in  all  directions  ;  the  vaginal  vault  is  soft  and  boggy  ; 
the  presenting  part  can  not  be  plainly  felt  ;  pulsating  vessels  are 
detected  around  the  cervix  ;  the  external  os  is  dilated  and  the 
cervical  canal  is  patulous  to  the  internal  os,  through  which  a 
finger  can  easily  be  pushed.  Under  favorable  conditions  the 
placenta  may  be  felt  through  the  abdominal  walls,  as  was  first 
pointed  out  by  Spencer.  Finally  the  maternal  face  of  the  placenta 
or  its  margin  is  felt  over  the  internal  os,  the  uneven  surface  of  the 
cotyledons  and  a  gritty  feel  distinguishing  it  from  a  blood-clot, 
the  membranes,  or  the  presenting  part. 

During  the  first  stage  of  labor  the  causes  of  hemorrhage  are 
lacerations  of  the  birth-canal,  rupture  of  blood-vessels,  and 
placenta  prsevia.  The  hemorrhage  of  placenta  praevia  occurs 
early,  with  unruptured  membranes,  with  feeble  pains  or  in  their 
absence  altogether,  and  the  symptoms  of  uterine  rupture  and  of 
lacerations  along  the  lower  birth-canal  are  absent.  In  the  rare 
event  of  a  ruptured  blood-vessel  along  the  lower  birth-canal,  the 
blood  does  not  flow  from  the  uterine  cavity. 

Treatment. — If  a  placenta  praevia  is  detected  during  preg- 
nancy, gestation  should  be  terminated  at  the  end  of  the  seventh 
month,  or  at  any  time  thereafter  that  the  diagnosis  is  estab- 
lished. The  hemorrhage  before  the  thirty-second  week  is 
scarcely  ever  dangerous,  ^  though  in  one  case  I  was  obliged  to 
induce  abortion  before  the  fifth  month  on  account  of  a  loss  of 
blood  that  was  almost  incessant.  After  the  seventh  month  the 
woman  may  bleed  to  death  at  any  time  before  medical  aid  can 
reach  her.  The  induction  of  labor  and  its  conduct  should  be  as 
follows  :  Send  for  an  assistant  to  administer  an  anesthetic ; 
place  the  woman  in  the  lithotomy  position,  with  her  knees  sup- 
ported by  nurses  or  attendants  ;  cleanse  both  hands  and  arms  as 
for  a  surgical  operation  and  put  on  sterile  rubber  gloves;  wash 
the  ^■ulva  and  the  vagina  with  tincture  of  green  soap  and  hot  water 

-  In  the  1 28  deaths  of  Miilki's  statistics  there  was  not  one  before  the  seven  tli  month. 
37 


578 


THE  PATHOLOGY  OF  LABOR. 


Fig.  459. — One  leg  has  been  drawn  down,  so  that  the  os  is  tamponed  and  the 
placenta  directly  compressed  by  the  hips  of  the  child  (Miiller). 


LABOR    COMPLICATED   BY  ACCIDENTS  AND   DISEASES.     579 

by  means  of  pledgets  of  cotton;  give  a  vaginal  douche  of  bichlorid 
of  mercury  1:4000;  dilate  the  cervix  by  inserting  first  one  finger, 
then  a  second,  and  next  the  thumb  of  the  right  hand ;  search  on  the 


'^/ 


Fig.  460. — Placenta  previa:  vagina  tamponed  with  gauze  (Dickinson). 

woman's  left  side  for  the  edge  of  the  placenta;  pass  two  fingers 
beyond  it:  perform  bipolar  version,  assisted  by  the  left  hand 
externally;  rupture  the  membranes;  seize  a  foot  and  extract  it 
until  the  knee  appears  at  the  vulva;  then  withdraw  the  anesthetic. 
If  the  bleeding  has  been  alarming  up  to  this  time,  it  will  cease  as 
soon  as  the  child's  breech  is  impacted  in  the  pelvic  canal.  From 
time  to  time  the  protruding  leg  may  be  gently  pulled  upon  to  hasten 
the  dilatation  of  the  cervical  canal,  but  plenty  of  time  must  be 
allowed  for  it ;  otherwise  the  head  is  caught  by  the  circular  filx-rs  of 
the  cervix  and  the  child  is  asphyxiated  by  the  pressure  u])()n  the 
cord.  At  the  expiration  of  an  hour  or  more  the  child  may  be 
safely  extracted.  If  the  operator  finds  a  rigid  cer\i\  and  ex- 
periences great  difficulty  in  its  manual  dilatation,  he  may  cmj^loy 
Voorhees'  bags;  but  under  anesthesia,  and  with  a  fair  amount 
of  strength  in  one's  fingers,  hydrostatic  dilatation  is  scarcely  ever 
required.     Instrumental  rlilatation  fBossi's  dilator)  is  not  recom- 


58o 


THE   PATHOLOGY  OF  LABOR. 


mended,  as  the  hemorrhage  would  be  more  profuse  than  it  is  with 
the  pressure  of  the  hand  or  a  bag  in  the  lower  uterine  segment  which 
partially  controls  it,  and  the  deep  lacerations  of  the  cervix  caused 
by  rapid  instrumental  dilatation  add  to  the  bleeding.  If  a  physi- 
cian discovers  placenta  prsevia  for  the  first  time  in  labor  by  a  profuse 
outpour  of  blood  when  the  dilatation  of  the  cervical  canal  begins,  he 
should  immediately  pack  the  vagina  as  full  as  it  can  possibly  be 
packed.  The  best  material  for  this  purpose  is  iodoform  or  sterile 
gauze  if  it  is  at  hand,  but  a  clean  towel  torn  into  strips  will  answer. 
The  tampon  serves  the  double  purpose  of  controlling  the  hem- 
orrhage and  assisting  the  dilatation  of  the  os.     After  a  delay  of 


Fig.     461. — Braun's   colpeurynter  used  as   a   metreurynter  in  placenta  previa:  a, 
bleeding  utero-placental  vessels  (Bumm). 

an  hour  or  two  to  allow  time  for  the  os  to  dilate,  the  patient  is  anes- ' 
thetized  and  the  operator  proceeds  as  before  described.  If  there 
is  great  difficulty  in  finding  the  margin  of  the  placenta  and  the 
membranes  beyond  it,  too  much  time  should  not  be  lost  in  the 
search.  The  placenta  should  be  perforated  and  the  child's  leg 
pulled  through  the  perforation.  If  the  operator  distrusts  his 
ability  to  perform  the  version  as  quickly  as  it  should  be  done  (for 


LABOR    COMPLICATED    BY  ACCIDENTS  AND   DISEASES.     58 1 

the  hemorrhage  is  hkely  to  be  furious  during  the  attempt),  he  may 
adopt  a  plan  of  treatment  proposed  by  Wigand  at  the  end  of  tlie 
eighteenth  century.  This  consists  in  tamponing  the  vagina  firmly 
and  allowing  the  tampon  to  remain  in  place  till  the  os  is  fulh^  di- 
lated. If  the  labor  lasts  too  long,  the  tampon  must  be  removed,  the 
vagina  douched,  and  a  fresh  tampon  inserted.  It  is  well  to  u'lite 
with  the  tampon  treatment  the  procedure  recommended  by 
Barnes — separating  the  placenta  by  a  sweep  of  the  fingers  around 
and  beyond  the  internal  os.  This  plan  v/as  suggested  by  the 
clinical  observation  that  when  the  placenta  separated  and  the 
presenting  part  descended  the  hemorrhage  ceased.  The  com- 
bination of  the  Barnes  and  the  Wigand .  treatment  gives  fairly 
good  results  for  the  mother,  though  it  increases  the  risk  of  the 
sepsis.  For  the  child  it  would  seem  to  be  bad,  but  we  have 
testimony  from  Wigand,  Murphy,  and  Winckel  to  the  contrary. 
The  fetal  mortahty  is  48.5  per  cent.  (Winckel).  In  cases  of 
marginal  placenta  praevia  in  which  hemorrhage  first  occurs  after 
the  OS  is  fairly  well  dilated,  in  which  the  head  presents  and  is  easily 
accessible,  the  best  treatment  is  rupture  of  the  membranes,  ap- 
plication of  forceps,  and  traction  upon  the  head  till  the  bleeding 
ceases;  whereupon  the  instrument  may  be  removed  and  the  labor 
is  allowed  to  terminate  spontaneously. 

The  use  of  a  dilatable  rubber  bag  ^  (Braun's  colpeurynter  or 
Voorhees'  bags)  in  the  lower  uterine  segment  (Fig.  461)  should  be 
considered  in  cases  of  lateral  and  marginal  placenta  praevia.  It 
is  inserted  collapsed  and  sterile  (boiled)  through  a  cervical  canal 
admitting  one  or  two  fingers;  it  is  distended  with  water  by  a  David- 
son or  a  piston  syringe,  the  bag  resting  against  the  ]etal  surface  of 
the  placenta;  it  is  usually  necessary  to  rupture  the  membranes 
alongside  the  edge  of  the  placenta  to  place  it  properly;  the  tube 
attached  to  the  bag  is  clamped  with  an  artery  forceps;  from  time 
to  time  traction  is  made  upon  it  to  hasten  the  dilatation  of  the  os. 
As  soon  as  the  bag  can  be  pulled  through  the  cervical  canal  by 
moderate  force  it  is  removed ;  forceps  is  applied  if  the  head  is  pre- 
senting, a  foot  is  pulled  down  in  breech  presentations,  or  bipolar 
version  is  |)erformed. 

It  may  finally  be  necessary  to  detach  an  adherent  placenta,  to 
control  a  postpartum  hemorrhage,  and  to  treat  the  woman  for 
acute  anemia. 

Cesarean  section  for  placenta  prie\-ia,  in  the  author's  judgment, 
is  not  to  be  recommended.  Its  mortality  in  25  cases  has  been  20.8 
per  cent,  for  the  mother  and  66.6  per  cent,  for  the  infants.^  The 
maternal  death-rate  by  version  in  the  hands  of  experts  is  about 

1  See  tlie  excellent  article,  with  good  l^iljlioi^raphy,  by  Dr.  Lee,  "  Chicago  Medi- 
cal Recorder,"  1901,  p.  309,  "The  Use  of  the  Colpeurynter  in  Obstetric  Practice." 
^  Deaver,  "  Journ.  Am.  Med.  Assoc,"  April  30,  1904. 


582 


THE   PATHOLOGY  OF  LABOR. 


I  per  cent.,  while  the  child  has  at  least  one  chance  out  of  two. 
Unless  there  is  some  reason  more  than  ordinarily  urgent  for  saving 
the  latter  at  any  cost,  it  does  not  seem  right  to  subject  the  mother 
to  an  extra  risk,  such  as  would  be  involved  in  a  Cesarean  section 
performed  by  physicians  in  general.  An  expert  might  expect 
cTood  results,  but  he  would  usually  obtain  the  same  by  less  radical 


Fig.  462. — Showing  separation  of  the  placenta  with  external  bleeding  (Dickinson). 

means.  Occasionally,  as  in  Webster's  case  of  a  thirteen-year-old 
girl  with  a  narrow  vagina  and  vulva,  and  in  a  case  of  the  author's 
complicated  by  contracted  pelvis  and  overgrown  fetus,  Cesarean 
section  should  be  performed,  but  ordinarily  version,  the  tampon 
or  the  metreurynter  will  give  better  results. 

Prognosis. — The  study  of  the  mortuary  statistics  of  placenta 
prsevia  is  not  very  profitable.  It  appears  that  the  maternal  death- 
rate  in  general  has  been  about  20  per  cent.,  including  the  deaths 
from  sepsis.^  But  with  the  plan  of  treatment  just  described,  car- 
ried out  by  men  who  understand  aseptic  methods,  the  mortality 
almost  disappears.  Thus,  Lomer  (16),  Hofmeier  (37),  Behm 
(35),  and  the  writer  (36)  have  had  116  cases,  with  2  deaths  (Hof- 
meier's  and  the  author's).  In  344  cases  of  placenta  prsevia  in 
Schauta's  clinic  in  Vienna  from  1903-1905,  treated  by  rupture 
of  the  membranes,  dilatable  bags,  and  combined  version,  the  mater- 
nal mortality  was  5.85  per  cent.,  and  in  274  cases  in  Zweifel's  clinic 
the  mortality  was  8  per  cent.,  making  618  cases,  with  a  mortality 

1  Fiith  found  in  the  district  around  Coblenz,  in  726  cases,  a  death  rate  of  20  per 
cent,  in  general  practice,  "  Zentralbl.  f.  Gyn.,"  p.  329,  1907. 


LABOR    COMPLICATED  BY  ACCIDENTS  AND  DISEASES.     583 


of  6.92  per  cent.  For  the  children  a  mortahty  of  50  per  cent, 
may  be  expected.  The  outlook  for  the  child  is  worse  the  more 
nearly  the  placenta  previa  is  central. 

Premature   Detachment  of  a  Normally  Situated  Placenta. — The 

placenta  may  become  detached  during  pregnancy  or  before  the 
third  stage  of  labor,  though  it  occupy  a  normal  position  near  the 
fundus  uteri.  The  necessary  consequence  is  hemorrhage,  often 
called  "accidental,"  to  distinguish  it  from  the  "unavoidable" 
hemorrhage  of  placenta  praevia.  If  the  lower  margin  of  the  pla- 
centa is  detached,  the  blood  separates  the  membranes  from  the 
uterine  wall  and  escapes  externally.  The  bleeding  may,  how- 
ever, be  entirely  concealed  (i)  if  the  center  of  the  placenta  is 
alone  detached ;  (2)  if  the  upper  margin  is  detached  and  the 
blood  accumulates  between  the  membranes  and  the  uterine  wall ; 
(3)  if  the  membranes  are  ruptured  far  from  the  internal  os  and 
the  blood  mingles  with  the  liquor  amnii ;  (4)  if  the  cervix  is  ob- 
structed by  a  blood-clot, 
the  membranes,  or  the  pre- 
senting part  (Goodell). 
Concealed  hemorrhage  is, 
fortunately,   rare. 

Causes. — The  cause  of 
premature  detachment  of 
the  placenta  may  be  ob- 
scure. The  accident  ma\- 
occur  during  sleep  and 
without  ascertainable  cause. 
The  causes  are  often,  how- 
ever, those  of  abortion  : 
nephritis,  congestion  of  the 
pelvis,  external  violence, 
physical  effort,  emotion. 
Prolongation  of  pregnancy, 
with  irregular  uterine  con- 
tractions, was  accountable 
for  one  of  my  cases.  Death 
and  disease  of  the  fetus, 
hydramnios,  a  short  um- 
bilical cord,  and  multiple 
pregnancy  may  cause  it.  It 
occurs  more  frequently  in 
multiparze  and  toward  the 
close  of  pregnancy. 

Frequency. — Holmes  ^  estimates  the  frequency  at  1-200  preg- 

1  "Ablatio  placentee"  ;  "Am.  Jour,  of  Obstetrics,"'  vol.   xliv,  1901,  a  study  of 
200  reported  cases ;  also,  "Jour.  Am.  Med.  Assoc,"  p.  1845,  1908. 


Fig.  463. — Premature  detachment  of  the 
placenta  occupying  its  normal  site.  P>ozen 
section  of  an  undelivered  woman  dead  of 
eclampsia.  A  blood-mass  under  the  placenta 
(after  Winter). 


584 


THE   PATHOLOGY   OF  LABOR. 


nancies,  but  in  only  1-500  cases  is  the  separation  serious  enough 
to  demand  attention. 

Symptoms  and  Diagnosis. — Accidental  hemorrhage,  especially 
if  concealed,  should  be  recognized  without  delay.  The  accident 
usually  occurs  before  labor  begins  or  in  the  first  stage.  The  uterine 
contractions  usually  become  weak  and  finally  cease,  being  re- 
placed by  persistent  and  severe  pain,  usually  at  the  placental  site, 
but  occasionally  the  uterus  is  thrown  into  a  tetanic  contraction 
of  the  most  violent  character,  associated  with  excruciating  pain. 
There  is  shock,  the  signs  of  internal  hemorrhage  becom.e  more  and 
more  apparent,  and  the  uterus  is  distended  by  the  accumulation  of 
blood  within  it.  Feeble  but  persistent  contraction  of  the  upper 
part  of  the  uterine  muscle  may  be  felt.  If  there  is  a  retroplacental 
effusion,  a  localized  bulging  at  the  placental  site  miay  be  made  out 
by  abdominal  palpation. 

The  s}-mptoms  resemble  somewhat  those  of  rupture  of  the 
uterus.    In  both  there  are  hemorrhage,  shock,  and  perhaps  sudden 

excruciating  pain.   But  in  rup- 


Unperend 
ofciot  "^ 


ture  of  the  uterus  the  accident 
occurs  late  in  labor,  the  mem- 
branes are  broken,  the  pre- 
senting part  recedes,  the  uterus 
is  well  contracted,  and  per- 
haps its  contents  are  evacu- 
ated into  the  peritoneal 
ca\ity;  while  in  accidental 
hemorrhage  the  detachment 
of  the  placenta  occurs  earh-  in 
labor,  the  membranes  are  not 
ruptured,  the  presenting  part 
does  not  recede,  and  in  con- 
cealed hemorrhage  the  uterus 
is  distended  by  the  accumu- 
lated blood.  In  frank  acciden- 
tal hemorrhage  the  diagnosis 
rests  between  detachment  of  a 
normall}'  situated  placenta  and 
placenta  praevia.  The  pres- 
ence or  absence  of  the  latter 
is  determined  by  a  careful  in- 
ternal examination. 

In     exceptional     cases     a 

frank    accidental    hemorrhage 

appears  as  earh*  in  pregnancy 

as  the  fourth  month.      Abortion  usually  follows,  but  I  have  seen 

two  cases  in  which  the  bleeding    continued   uninterruptedly   for 


IS  ;,7fj- 
•r/'/z'ja'ierenr 
b  uffrus. 


oPc/ot 


Fig.  464- — Accidental  hemorrhage. 
Blood  collected  between  placenta  and  part 
of  membranes  and  the  uterine  wall  (Pinard 
and  \'arnierj. 


LABOR    COMPLICATED   BY  ACCIDENTS  AND  DISEASES.     585 

weeks,  a  large  blood-clot  formed  between  the  site  of  the  placental 
separation  and  the  external  os,  and  septic  symptoms  supervened. 
In  spite  of  these  unfavorable  conditions  pregnancy  continued,  and 
the  fetus  lived  until  I  was  obliged  to  terminate  gestation  on  ac- 
count of  the  anemia  and  the  s_\-mptoms  of  systemic  infection. 

Prognosis. — The  mortalit}'  in  accidental  hemorrhage  is  high. 
Goodell's  statistics  give  54  maternal  deaths  out  of  107  cases,  and 
of  the  108  children  (there  being  one  case  of  twins)  only  7  were 
saved.      Holmes'  statistics  {ioc.  cit.)  give  a  much  lower  mortality. 

Treatment. — The  main  object  of  treatment  is  to  evacuate  the 
womb  as  speedily  as  possible,  so  that  the  uterine  muscle  may 
contract.  At  the  same  time  it  must  be  remembered  that  the 
woman  is  in  no  condition  to  endure  mxuch  additional  shock.  The 
best  procedure  is  to  dilate  the  cervix  with  rubber  bags  or  with 
the  fingers,  to  perforate  the  membranes,  and  then  to  extract 
the  child  by  the  quickest  plan  available.  If  the  presenting  part 
is  not  engaged,  the  child  should  be  rapidly  extracted  by  the 
leg.  If  the  head  is  engaged  and  a  rapid  forceps  operation  is 
practicable,  the  instrument  should  be  emplo}'ed.  If  not,  crani- 
otomy should  be  performed.  Ergot  should  be  administered 
hypodermatically,  for  postpartum  hemorrhage  is  to  be  feared. 
A  Cesarean  section  should  be  considered  in  the  gravest  cases,  in 
which  a  continuance  of  hemorrhage  and  the  shock  of  a  forced 
delivery  are  more  to  be  dreaded  than  abdominal  section  and  puer- 
peral hysterectomy. 

Rupture  of  the  circular  sinus  of  the  placenta  may  give  rise 
to  symptoms  indistinguishable  from  those  of  premature  detach- 
ment, and  calling  for  the  same  treatment.  ^ 

Postpartum  Hemorrhage. — Hemorrhage  may  occur  during  the 
third  stage  of  labor,  or  in  the  first  twenty-four  hours  of  the  puer- 
perium,  from  relaxation  of  the  uterine  muscle,  from  injuries  along 
the  birth-canal,  from  ruptured  vessels,  tumors,  malignant  growths, 
or  ulceration  in  the  parturient  tract. 

Postpartum  Hemorrhage  from  Relaxation  of  the  Uterine  Muscle. 
— When  the  placenta  is  separated  from  the  uterine  wall  and  the 
large  maternal  blood-vessels  communicating  with  it  are  neces- 
sarily torn  across,  every  woman  after  labor  would  bleed  to  death 
were  it  not  for  the  following  provisions  on  the  part  of  nature  to 
prevent  hemorrhage :  Leukocytes  begin  to  block  the  uterine 
sinuses  in  the  latter  weeks  of  pregnancy,  and  the  excess  of  the 
fibrin-making  elements  in  the  blood  of  pregnant  women,  together 
with  the  sluggish  blood-current  in  the  sinuses,  favor  the  forma- 
tion of  firm  blood-clots  in  their  orifices  when  they  arc  torn  ;  the 
uterine  muscle  contracts  the  moment  the  uterine  cavity  is  emptied, 

'  Mynlieff  has  collected  30  cases,  <' Diss.  Inaug.,  Amsterdam,"  refer.  "Jahres- 
bericht,"  vol.  xii,  1899,  p.  757. 


586  THE   PATHOLOGY  OF  LABOR. 

SO  that  the  blood-channels  running  through  the  uterine  walls  are 
ligated  throughout  their  whole  length  by  the  contracting  muscle- 
fibers  that  encircle  them  ;  the  quality  of  retraction  in  the  uterine 
muscle  maintains  what  is  gained  by  contraction.  It  is  to  the  last 
two  actions  mainly  that  a  woman  owes  her  immunity  from  hemor- 
rhage after  labor. 

The  causes  of  postpartum  hemorrhage  are,  therefore,  those 
which  interfere  with  uterine  contraction.  They  are  :  Systemic 
weakness  from  disease  ;  unfavorable  hygienic  surroundings  or 
anxiety  ;  weakness  in  the  uterine  muscle-fibers  themselves,  as 
when  they  are  undeveloped,  fatigued,  overstretched  by  hydram- 
nios  or  twins,  inactive  by  reason  of  surrounding  inflammatory 
products,  exhausted  by  many  previous  labors,  or  too  suddenly 
called  upon  to  contract  by  a  rapid  labor,  especially  if  it  is  instru- 
mental ;  anomalies  in  the  innervation  of  the  muscle-fibers  ;  a 
mechanical  obstacle  to  firm  contraction,  as  a  retained  placenta  or 
clots  within  the  womb,  old  adhesions  upon  its  peritoneal  surface, 
or  a  tumor  such  as  a  uterine  fibroma,  an  ovarian  cyst,  a  dis- 
tended bladder  or  rectum,  that  by  its  bulk  keeps  the  womb 
distended  or  displaces  it.  Some  sudden  effort  may  displace  the 
clots  in  the  uterine  sinuses  and  thus  favor  hemorrhage,  as  cough- 
ing, sneezing,  s'.tting  up  in  bed,  or  defecation.  Heart  and  lung 
disease  or  arterial  tension  from  any  cause  may  produce  a  conges- 
tion of  the  womb  that  predisposes  to  postpartum  hemorrhage. 

Symptoms  and  Diagnosis. — There  is  no  difficulty  in  recogniz- 
ing postpartum  hemorrhage  when  the  blood  soaks  through  the 
mattress  and  runs  across  the  floor  in  a  stream.  The  bleeding 
should  be  detected  early,  however,  that  it  may  be  arrested  at 
once.  There  is  usually  a  sudden  gush  of  blood,  followed  by 
the  expulsion  every  {q.\n  seconds  of  several  ounces  of  liquid 
blood  and  clots.  The  uterus  is  relaxed  and  it  is  difficult  to 
outline  it  through  the  abdominal  wall.  There  is  an  absence  of 
that  firm,  round,  easily  palpable  tumor  usually  filling  the  hypo- 
gastrium,  characteristic  of  a  firmly  contracted  womb.  The  con- 
stitutional signs  of  hemorrhage  become  rapidly  more  and  more 
evident.  The  face  is  blanched,  the  pulse  is  quick  and  feeble, 
vision  fails,  there  is  air-hunger,  and  the  woman,  to  satisfy  her  in- 
stinctive craving  for  more  oxygen  in  the  rapidly  emptying  blood- 
vessels, makes  a  curious  sound  between  that  of  a  gape  and  a  sigh. 
Finally,  there  are  restlessness,  jactitation,  convulsions,  coma,  and 
death. 

In  exceptional  cases  one  tremendous  outpour  of  blood,  last- 
ing not  more  than  five  minutes,  kills  the  patient.  One  can  not 
always  judge  the  extent  of  the  hemorrhage  by  the  amount  of 
blood  that  escapes  externally.  The  dilated  womb  may  contain 
enough  within  its  cavity  to  cost  the  woman  her  life. 


LABOR  COMPLICATED  BY  ACCIDEXTS  AND  DISEASES.     587 

Very  rarely,  indeed,  an  uncontrollable  postpartum  hemorrhage 
is  seen  from  a  firmly  contracted  and  an  uninjured  uterus.  It 
occurred  once  from  a  ruptured  aneurysmal  vessel;  again  in  con- 
nection with  nephritis,  presumably  from  atheromatous  or  diseased 
vessels ;  in  one  case  from  a  ruptured  hematoma  of  the  cervix  ; 
in  another  from  ulceration  of  the  cervix  that  opened  the  uterine 
artery  ;  in  another  from  a  ruptured  varicose  vein  in  the  cervix. 
Cases  have  been  reported  of  paralysis  of  the  placental  site,  with 
firm  contraction  of  the  remainder  of  the  womb.  ^ 

In  high  altitudes  postpartum  hemorrhage  is  said  to  be  much 
more  common  than  at  lower  levels,  from  the  lessened  atmos- 
pheric pressure.  I  have  been  told,  by  physicians  practising  in 
the  high  regions  bordering  upon  the  Rocky  Mountains  and  in 
South  Africa,  that  they  have  this  complication  to  contend  with 
very  frequently. 

Treatment. — Postpartum  hemorrhage  may  occur  after  any 
labor.  Measures  to  prevent  it  consequently  form  part  of  the 
routine  management  of  labor,  as  already  described.  If  any 
of  the  predisposing  causes  of  uterine  relaxation  exist  during 
labor,  additional  precautions  should  be  taken.  As  soon  as  the 
presenting  part  emerges  from  the  vulva,  ergotin  should  be  injected 
into  the  woman's  thigh,  the  placenta  should  be  expressed  without 
too  much  delay,  and  the  womb  should  be  kneaded  and  compressed 
more  vigorously  and  for  a  longer  time  than  usual,  until  it  remains 
firmly  contracted  and  shows  no  disposition  to  relax.  Then  a  large 
abdominal  pad  should  be  laid  above  the  umbilicus  and  a  firm  ab- 
dominal binder  should  be  adjusted.  The  nurse  should  receive 
instructions  to  watch  the  patient's  appearance  closely,  to  count  the 
pulse  frequently,  and  occasionally  to  turn  down  the  bedclothes  and 
observe  the  quantity  of  the  discharge. 

Should  hemorrhage  occur  in  spite  of  these  precautions,  it 
must  be  controlled  with  the  least  possible  delay,  for  so  much 
blood  is  lost  in  a  short  time  that  the  woman  may  die  of  acute 
anemia,  even  though  the  bleeding  be  finally  checked. 

The  beginner  will  do  well  to  bear  in  mind  the  following  plan 
of  action  that  he  may  put  it  into  immediate  effect,  without  de- 
pending too  much  upon  his  presence  of  mind,  readiness  of  re- 
source, or  self-command — qualities  that  perhaps  are  lacking 
when  he  is  first  confronted  with  one  of  the  most  alarming  acci- 
dents of  obstetric  practice  : 

Seize  the  fundus  uteri  with  one  hand  through  the  anterior 
abdominal  wall  ;  knead,  compress,  and  rub  it  vigorously  with 
the  fingers  applied  to  the  posterior  uterine  wall,  the  palm  to  the 
fundus  and  the  tKumb  in  front,  until  the  womb  is  felt  firmly  con- 
tracting.    If  external  irritation  does  not  effect  the  desired  result, 

1  Miiller's  "  Ilandhuch,"  Veit,  vol.  ii,  pp.  121,  130. 


588 


THE   PATHOLOGY  OF  LABOR. 


insert  the  free  gloved  hand  into  the  vagina,  pass  it  into  the  uterine 
cavity,  feel  for  retained  fragments  of  the  placenta,  blood-clots,  or 
other  substances  that  might  by  their  bulk  prevent  contraction,  re- 
move them,  and  while  doing  so  rotate  the  hand  somevv^hat  roughly, 
so  as  to  bring  it  in  contact  rather  forcibly  w^ith  the  uterine  wall;  at 
the  same  time  continue  the  kneading,  rubbing,  and  compression 
externally.  If  the  combined  irritation  of  the  exterior  and  interior 
of  the  womb  fails  to  secure  firm  contraction,  try  next  the  irri- 
tating effect  of  cold.  Rub  a  piece  of  ice  upon  the  hypo- 
gastrium.  If  the  effect  of  cold  is  not  immediately  satisfactory, 
do  not  persist  in  its  use,  for  the  ultimate  effect  is  relaxing 
rather  than  stimulating.  A  ready  and  convenient  method  of 
violently  chilling  the  hypogastric  region  is   to  pour  some  ether 


Fig.  465. — Packing  the   puerperal  uterus  with  gauze  to  control  postpartum  hemor- 
rhage (Edgar).    " 


upon  it.  The  irritation  of  cold  externally  having  proved  in- 
effective, the  uterine  cavity  should  be  packed  with  iodoform  or 
sterile  gauze.  In  the  intrauterine  tampon  we  possess  the  surest 
and  most  reliable  means  of  controlling  ])ostpartum  hemorrhage.' 
The  technic  of  inserting  the  tampon  is  shown  in  figure  465.  The 
end  of  the  strip  should  be  inserted  as  far  as  the  fundus  by  a  long 

1  Diihrssen,    "  Ueber    die    Ueliandlung    der    Blutungen  post  partitm^'    Volk- 
mann'sche  Sainmlung,  347. 


LABOR    COMPLICATED   BY  ACCIDENTS  AND  DISEASES.     589 

placental  forceps,  and  the  whole  uterine  cavity  firmly  ])acked  with 
the  successive  layers. 

Other  agents  of  value  in  promoting  uterine  contraction  are  hot 
water,  electricity,  and  styptic  or  irritating  drugs,  such  as  Monsel's 
solution,  iodin,  and  turpentine.  An  intra-uterine  injection  of  very 
hot  water  (120°  F.)  is  effective,  but  it  is  difficult  to  regulate  the 
temperature  in  private  practice,  and  if  this  means  fails,  valuable 
time  has  been  lost.  A  strong  faradic  current  is  extremely  efficient, 
but  a  battery  is  scarcely  ever  at  hand  when  it  is  needed. 


Fig.  466. — Holmes'  uterine  tube  and  packer. 


Monsel's  solution  will  stop  the  bleeding,  but  it  leaves  such  firm 
and  adherent  clots  in  the  uterine  cavity  that  septicemia  will  very 
likely  follow  from  their  decomposition,  and  there  is  danger,  besides, 
of  an  extension  of  the  thrombosis  to  the  uterine  and  pelvic  vessels. 
Iodin  and  turpentine  have  done  good  service  by  their  irritating 
qualities,  but  there  is  danger  of  metritis  from  their  use,  and  they 
might  leak  into  the  abdominal  cavity  through  the  tubes.  Great  vir- 
tue has  been  claimed  for  special  modes  of  compressing  the  uterus 
(Fig.  467)  that  are  supposed  to  close  the  mouths  of  the  bleeding 
vessels.  Fritsch  advocates  pressing  the  uterus  forward  and  down- 
ward over  the  symphysis  pubis,  putting  a  large  compress  behind 
and  above  it,  and  applying  a  tight  abdominal  binder.  When 
these  methods  are  effective  it  is  by  irritating  the  uterine  muscle, 
rather  than  by  the  pressure  exerted  ujjon  the  \'cssels  of  the  p^laccntal 
site.  Compression  of  the  abdominal  aorta  has  been  proposed  as 
a  means  of  checking  postpartum  hemorrhage  by  diminishing  the 
blood  supply  to  the  womb.  This  plan,  in  my  opinion,  is  absurd. 
When  it  has  apparently  succeeded  it  was  by  the  irritation  of  the 
womb,  or  of  the  synijjathetic  nerves  supplying  it,  on  account  of 
the  deep  alxlominal  jjressure  above  the  fundus. 


590 


THE   PATHOLOGY  OF  LABOR. 


A  plan  well  worth  remembering  that  has  succeeded  when  others 
have  failed  is  to  seize  the  lips  of  the  cervix  with  bullet  forceps  and 
to  pull  the  uterus  forcibly  downward.  All  operators  know  that 
hemorrhage  during  an  operation  on  the  uterus  may  be  controlled 
in  this  way. 

Finally,  the  bleeding  may  cease  spontaneously  by  thrombus 


Fig.  467. —  Bimanual  compression  of  the  uterus. 


lormation    or   b}'   syncope,  but  these  agencies    are   never  to  be 
awaited  in  practice. 

The  ph\-sician's  dut}'  is  not  always  done  when  he  has  checked 
the  bleeding.  An  acute  anemia  must  be  dealt  with  that,  if  dis- 
regarded, is  as  dangerous  as  a  continuance  of  the  hemorrhage. 
There  is  a  rapid,  feeble  pulse ;  or,  it  may  be,  an  entire  ab- 
sence of  radial  pulsation.  The  body-sufface,  especially  of  the 
extremities,  is  cold,  and  there  is  a  disposition  to  syncope  on  the 
slightest  effort.  There  is  loss  of  vision,  and  the  acute  anemia  of 
the  brain  may  even  lead  to  convulsions.  With  the  dangers  of 
heart-failure  and  cerebral  anemia  in  mind,  the  physician,  while 
engaged  in  stopping  the  bleeding,  directs  the  nurse  to  raise  the 
foot  of  the  bed  on  some  books,  bricks,  or  the  seats  of  chairs,  and, 
if  there  is  a  tendency  to  repeated  syncope ,  to  give  a  hypodermic 
injection  of  ether;  or  of  nitroglycerin  Ctwo  drops  of  one  per  cent, 
solution).  As  soon  as  the  hemorrhage  is  checked,  an  enema  of 
a  pint  of  hot  water  containing  about  forty  grains  of  common  salt 
should  be  given.  The  patient  should,  in  addition,  be  surrounded 
by  hot  bottles,  should  be  well  covered  with  blankets,  and  should 
be  kept  at  absolute  rest,  with  the  body  and  head  on  a  straight  line 
and  the  foot  of  the  bed  well  elevated  to  keep  as  much  blood  as 
possible  in  the  brain.  Heart-stimulants— digitalis,  strychnin, 
nitroglycerin,  and  ether — should  be  given  hypodermatically  if  the 


LABOR    COMPLICATED   BY  ACCIDENTS  A  AD   DISEASES.    59I 

heart-action  fails  to  improve.  There  is  likely  to  be  nausea  and 
vomiting,  but,  as  soon  as  the  stomach  will  retain  what  is  put  in  it, 
the  woman  should  receive  very  small  quantities  of  hot  milk,  hot 
concentrated  coffee,  hot  water  and  brandy,  frequently  repeated. 
When  reaction  is  once  estabhshed,  a  hypodermatic  injection  of 
morphin  hastens  the  patient's  recovery  from  the  effects  of  the 
hemorrhage  and  prevents  secondary  shock  by  promoting  physical 
quiet,  calming  nervous  restlessness,  and  producing  some  degree  of 


Fig.  468. — Intravenous  injection. 


cerebral  congestion.  In  desperate  cases  in  which  the  measures 
just  described  are  without  satisfactory  result,  a  pint  to  a  quart 
of  a  sterile  normal  salt  solution  (0.6  per  cent.),  at  blood  heat, 
should  be  injected  by  gravity  into  the  loose  cellular  tissue  be- 
tween the  shoulder-blades  (hypodermoclysis),  under  the  breasts, 
or  directly  into  an  artery  or  a  vein.  A  convenient  apparatus  for 
this  purpose  is  shown  in  figure  468.  A  good  substitute  for  the 
transfusion  apparatus  is  a  large  aspirating  needle  and  a  fountain 
syringe  or  funnel.  With  this  appliance,  with  which  every  obstet- 
rician should  be  provided,  fluid  may  be  forced  into  the  cellular 
tissue  under  the  breasts  or  into  a  blood-vessel.  The  funnel  and 
needle  should  have  a  place  in  every  well-supplied  obstetric-instru- 
ment bag. 

The  extremities  should  be  bandaged  toward  the  trunk  (auto- 
infuslon)  so  as  to  force  as  mucli  blood  as  possible  to  the  heart, 
the   large  blood-channels,  and  the    brain.     Compression   of  the 


592  THE   PATHOLOGY  OF  LABOR. 

abdominal  aorta  helps  to  this  end.  Actual  transfusion  of  blood 
from  one  person  to  another,  or  from  some  animal,  is  not 
advisable.  It  is  rarely  practicable,  and  the  results  are  no  better 
than,  if  as  good  as,  those  obtained  by  the  injection  of  salt  solution. 

The  physician  should  make  it  an  invariable  rule  to  stay  with 
his  patient  until  her  condition  is  entirely  satisfactory.  The  anemia 
persisting  after  the  hemorrhage  is  checked  and  reaction  is  estab- 
lished should  be  treated  by  a  full  liquid  diet,  animal  broths,  and 
iron.  The  intense  headaches  of  cerebral  anemia  that  may  per- 
sist or  recur  for  some  time  are  best  treated  with  opium. 

Actual  transfusion  by  an  artificial  anastomosis  between  the 
radial  blood-vessels  of  a  healthy  volunteer  and  the  patient  is 
scarcely  ever  practicable  in  acute  hemorrhage.  It  may  be  consid- 
ered if  the  patient  fails  to  respond  to  the  treatment  just  described 
or  if  a  pernicious  degree  of  anemia  persists.  But  it  is  not  always 
successful,  and  is  not  free  from  the  risk  of  embolism. 

Lacerations  of  the  Walls  of  the  Birth=canal. — Any  portion  of 
the  soft  structures  surrounding  the  birth-canal,  from  the  fundus 
uteri  to  the  vulva,  is  liable  to  spontaneous  rupture,  or  to  trau- 
matic perforation  during  labor. 

Rupture  of  the  Uterus. — The  uterus  may  be  ruptured  by  over- 
distention  of  the  lower  uterine  segment.  It  may  burst  open  from 
top  to  bottom  in  certain  diseased  conditions  of  its  walls.  It  may 
be  penetrated  by  the  operator's  hands  or  by  instruments.  Its  wall 
may  be  perforated  by  a  localized  necrosis  and  ulceration.  If  the 
rupture  involves  all  the  coats  and  opens  a  v/ay  into  the  peritoneal 
cavity,  it  is  called  complete.  If  it  spares  the  peritoneal  covering 
of  the  uterus,  it  is  called  incomplete. 

Frequency. — The  statistics  of  the  frequency  of  ruptured  uterus 
vary  greatly. 

Bandl  found I  in     1200  labors. 

Jolly  found I  "  3403  " 

Lusk  found i  "  6000  " 

Collins  found I  "  482  " 

McClintock  found i  "  737  " 

Ramsbothan  found    ............  I  "  4429  " 

Garrigues  found ,..._..!"  3-50°°  " 

Winckel  found i  "  666  " 

Harris  found .    .    .  i  "  4000  " 

Koblanck  found I  "  462  " 

Rupture  of  the  uterus  is  much  more  common  in  the  poorer 
than  in  the  richer  classes,  chiefly  because  the  former  have  less 
skilful  medical  attendants.  Multiparae  are  more  liable  to  the 
accident  than  primiparae  (88  per  cent.  :  12  per  cent.,  Bandl).  Dis- 
ease of  the  uterine  wall,  as  fatty  degeneration,  a  myoma,  a  pre- 
vious injury  to  or  operation  upon  the  uterus,  as  a  former  rupture 
or  Cesarean  section,  are  predisposing  causes. 


LABOR  COMPLICATED  BY  ACCIDENTS  AND  DISEASES.     593 

Causes. — The  most  frequent  cause  of  ruptured  uterus  in  labor 
IS  overdistention  of  the  lower  uterine  segment,  due  to  some  ob- 
struction which  prevents  the  descent  of  the  child  through  the 
pelvic  canal.  1      Bandl  first  pointed  out  this  fact.  ^ 

In  a  normal  labor  the  lower  pole  of  the  uterine  ovoid  is  gradu- 
ally dilated  until  the  fetal  body  passes  through  it  into  the  vagina. 
If  there  is  an  insuperable  obstacle  to  the  descent  of  the  child,  as 
a  contracted  pelvis,  rigid  soft  parts,  a  tumor  in  the  pelvis,  over- 
growth or  enlargement  of  the  child,  hydrocephalus,  an  impossible 
presentation  or  position,  the  contraction  of  the  upper  uterine  seg- 
ment continues  until  the  child's  body  is  driven  in  great  part  out 
of  it,  but,  descent  of  the  child  being  prevented,  it  is  crowded  into 
the  enormously  distended  lower  uterine  segment  and  cervical 
canal,  while  the  firmly  contracting  upper  uterine  segment  is 
drawn  up  under  the  ribs  until  it  sits  upon  the  child's  body  like  a 
cap.  There  is  a  sharply  defined  line  between  the  firmly  con- 
tracted thick  wall  of  the  upper  uterine  segment  and  the  very  thin 
wall  of  the  distended  lower  uterine  segment,  a  line  visible  and 
palpable  running  across  the  abdomen  between  the  symphysis 
and  the  umbilicus,  approaching  nearer  the  latter  the  greater  the 
distention  of  the  lower  uterine  segment,  the  upper  boundary  of 
which  is  normally  about  the  level  of  the  pelvic  brim.  This  line 
is  called  the  "contraction-ring"  or  the  "ring  of  Bandl."  It 
ordinarily  coincides  with  the  coronary  vein  of  the  uterine  wall 
and  with  the  firm  attachment  of  the  peritoneum  to  the  uterus. 
It  is  not,  as  it  was  once  supposed  to  be,  the  margin  of  the  inter- 
nal OS  or  the  upper  limit  of  the  cervical  canal  ;  it  is  the  boundary- 
line  between  that  portion  of  the  uterine  muscle  which  contracts 
firmly  in  labor,  diminishing  the  area  of  intra-uterine  space  and 
driving  the  child  out  of  the  uterine  cavity,  and  that  portion  of  the 
uterine  muscle  which  must  be  distended  in  labor  to  allow  the 
passage  of  the  child  through  the  pointed  end  of  the  uterine  ovoid. 
If  there  is  a  greater  bulk  of  the  fetal  body  in  one  side  of  the  lower 
uterine  segment,  the  contraction -ring  is  higher  upon  that  side 
and  thus  runs  an  oblique  course  across  the  abdomen.  There  is 
a  limit,  of  course,  to  the  capacity  of  the  lower  uterine  segment 
and  to  the  stretching  and  tenuity  of  its  walls.  That  limit  being 
reached,  the  overstretched  wall  tears  and  the  fetus  may  pass  from 
the  uterine. into  the  abdominal  cavity.  In  rare  cases  the  uterine 
wall  is  weakened  by  a  previous  rupture,  by  a  blow  or  fall  during 
pregnancy,  by  the  scar  of  a  Cesarean  section,  or  by  the  removal 

1  A  contracted  pelvis  is  the  most  common  cause  of  uterine  rujituri-,  and  a  justo- 
minor  pelvis  is  the  kind  of  contracted  pelvis  most  often  accountalile  for  it.  In  I2i8 
ruptures  a  contracted  pelvis  was  the  cause  in  570  (Koblanck,  "  Uterusru[)tur, "  Stutt- 
gart, 1895).  ^  "  Ueber  Ruptur  der  (iebiirmutter, "  Wien,  1875. 

38 


594 


THE  PATHOLOGY  OF  LABOR. 


of  a  portion  of  the  uterine  wall  in  the  excision  of  a  myoma ;  the 
wall  may  be  weakened  by  fatty  degeneration,  associated,  perhaps, 
with  excessive  general  obesity  ;  ^  prolonged  pressure  upon  a  small 
area  may  destroy  its  vitality  and  lessen  its  resistance.  In  such 
cases  rupture  of  the  uterus  may  occur  early  in  labor,  or  even 
in  pregnancy,  without  distention  of  the  lower  uterine  segment. 
Finally,  external  violence  has  ruptured  or  perforated  the  wom.b, 
instruments  inserted  in  the  vagina  have  pierced  its  walls,  the  appU- 
cation  of  Crede's  method  to  express  an  adherent  placenta  "  and  the 
insertion  of  the  operator's  hand  in  the  uterine  cavity  to  perform 
version  have  been  the  immediate  cause  of  rupture.^ 


Fig.  469. — Laceration  of  lower  uterine  segment:   a,  Right  ovary;  b,  rectum; 
c,  laceration  ;  d,  left  tube  (Winckel). 


Morbid  Anatomy. — The  tear  in  the  uterine  wall  almost  always 
begins  in  the  lower  uterine  segment,  and  usually  runs  trans- 
versely. It  may  be  upon  the  anterior,  lateral,  or  posterior  sur- 
face. The  edges  of  the  tear  are  usualh'  ragged,  swollen,  and 
infiltrated  with  blood.  The  peritoneal  covering  of  the  uterus  is 
often  stripped  off  for  a  considerable  distance  beyond  the  tear,  and 
in  the  sac  thus  formed  between  the  peritoneum  and  the  body  of 

^  In  a  case  of  uterine  rupture  seen  with  Dr.  U.  G.  Heil,  of  Philadelphia,  the 
woman  had  become  suddenly  and  enormously  obese  before  her  last  pregnancy.  She 
had  experienced  no  special  difficulty  in  the  births  of  her  other  children,  but  in  the 
last  the  uterus  ruptured  after  a  few  hours  of  moderate  labor-pai:is. 

2  "  Monatschr.  f.  Geb.  u.  Gyn.,"  Sept.,  1003. 

3  Koblanck  [loc.  cif.')  gives  the  following  causes  in  80  cases:  Contracted  pelvis,  8; 
transverse  position  of  fetus,  7  ;  other  abnormal  positions,  4  ;  hydrocephalus,  4  ;  over- 
growth of  child,  I  ;  misfit  of  presenting  part  in  pelvis,  administration  of  ergot,  i  ;  vio- 
lence, 5  ;  version,  29;  Hofmeier's  grip,  i  ;  forceps,  II  ;  decapitation,  i ;  myoma,  i. 


LABOR  COMPLICATED  BY  ACCIDENTS  AND  DISEASES.     595 


Fig.  470. — Transverse  or  semicircular  tear  of  the  lower  uterine  segment. 


Fig.  471. — Laceration  of  lower  uterine  segment. 


596 


THE  PATHOLOGY  OF  LABOR. 


the  uterus  the  placenta  may  He  concealed,  or  even  the  fetus  may 
be  contained.  There  may  be  an  enormous  subperitoneal  hema- 
toma or  profuse  intraperitoneal  hemorrhage.  The  tear  may  run 
upward  toward  the  fundus,  or  may  extend  so  far  transversely  as 
almost  to  sever  the  upper  and  lower  uterine  segments.  The  rent 
may  extend  through  the  mucous  and  muscular  coats  without  in- 
volving the  peritoneum.  The  latter,  in  rare  cases,  may  alone  be 
split,  and  it  is  recorded  in  one  case  that  the  peritoneal  and  mus- 
cular coats  were  torn  while  the  mucosa  remained  intact.  ^  If  the 
tear  is  extensive  and  complete,  the  fetal  body  will  probably  pass 


Fig.  472. — Perforating  lacera- 
tion of  the  cervix  :  a,  Posterior  lip ; 
b,  anterior  lip  ;  c,  perforation. 


Fig.  473. — Perforating  laceration  of 
the  cervix  :  a,  Perforation  ;  b,  peritoneum ; 
c,  muscle  ;  d,  posterior  lip  of  the  cervix  ; 
e,  vaginal  laceration  (Winckel). 


into  the  abdominal  cavity,  and  intestines  may  prolapse  into  the 
uterus  and  into  the  vagina.  2  In  one  remarkable  case^  there  was  a 
tear  of  the  lower  uterine  segment  and  of  the  right  lateral  fornix 
of  the  vagina,  through  which  the  fetus  entered  the  vagina,  passing 
to  one  side  of  the  undilated  cervix.      Fetal   death  is  usually  syn- 

1  J.  M.  Withrowr  ("Lancet-Clinic,"  December,  1891)  reports  a  case  of  ruptured 
uterus,  the  rent  beginning  in  front,  midway  between  the  insertion  of  the  tubes,  ex- 
tending up  over  the  fundus  and  down  along  the  posterior  wall  to  Douglas'  pouch, 
involving  the  peritoneal  coat  and  the  muscular  tissue,  but  not  the  mucous  membrane. 
The  uterus,  filled  with  water  after  removal  from  the  body,  did  not  leak.  A  large 
dose  of  ergot  had  been  given  during  labor. 

^Crossen  reports  a  case  in  which  it  was  necessary  to  resect  13  feet  of  intestine 
prolapsed  through  a  rent  in  the  anterior  wall  of  the  uterus,  "  Am.  Gyn.  and  Obstet. 
Jour.,"  vol.  xii,  p.  45.  9-Slajmer,  "  Centralblatt  f.  Gyn.,"  No.  18,  1895. 


LABOR  COMPLICATED  BY  ACCIDENTS  AND  DISEASES.     597 


chronous  with  the  rupture  of  the  womb,  and  if  the  child's  body 
passes  into  the  peritoneal  cavity  it  rapidly  putrefies,  generating 
gases  of  decomposition  so  quickly  that  its  bulk  is  enough  in- 
creased to  make  its  extraction  difficult.  From  the  decomposition 
of  the  fetal  body,  or  perhaps  from  the  entrance  of  atmospheric 
air,  there  may  be  emphysema  of  the  pelvic  connective  tissue 
and  of  the  cellular  tissue  of 
the  thighs,  buttocks,  mons 
Veneris,  and  abdomen. 
Septic  peritonitis  of  a  viru- 
lent kind  usually  develops 
with  great  rapidity.  In  a 
minority  of  cases  the  site 
of  the  rupture  is  walled 
off  by  a  rapid  outpour  of 
lymph  and  by  agglutina- 
tion of  coils  of  intestines, 
leaving  a  comparatively 
small  cavity  to  be  drained 
through  the  tear.  This 
cavity  may  secrete  ascitic 
fluid  in  large  quantities 
for  a  time,  and  during 
the  woman's  convalescence 
there  may  be  a  profuse 
watery  discharge  from  the 
womb.  I  have  seen  two 
such  cases.  Occasionally  a 
large  area  of  intraperitoneal 
space  is  drained  through 
the  tear.  Even  the  fetal 
body  may  be  encapsulated, 

and  a  lithopedion  may  be  formed.  In  the  uterine  ruptures  or 
perforations  due  to  pressure  necroses  the  opening  is  round  in  shape, 
regular  in  outline,  and  small  in  extent.  The  opening  is  almost 
always  on  the  posterior  wall  over  the  promontory  of  the  sacrum. 
In  the  rare  cases  of  exostoses  of  the  pelvis  the  bony  outgrowth  may 
pinch  a  hole  in  the  uterine  wall.  In  these  cases  the  opening 
corresponds  to  the  site  of  the  exostosis. 

Clinical  History,  Syviptovis,  a)id  Diagnosis. — Rupture  of  the 
uterus  usually  occurs  after  labor  has  lasted  a  loni^  time,  after 
rupture  of  the  membranes,  and  with  a  well  dilated  os.  There  is 
usually  an  obstruction  in  the  labor  tliat  should  have  been  recog- 
nized, the  lower  uterine  secernent  is  enormoush'  distended,  and  the 
contraction-ring  is  palpable  and  visible  near  the  umbilicus  ;  the 
pains  have  been  vigorous  and  frequent,  the  woman's  suffering  has 


Fig.  474. — Uterus  perforated  by  the  pres- 
sure of  the  promontory :  a,  Perforation ;  b, 
laceration  of  the  cervix;  c,  c,  c,  vaginal  tears; 
d,  contraction  ring;  e,  posterior  lip  of  cervix 
(Winckel). 


598 


THE  PATHOLOGY  OF  LABOR. 


been  extreme,  and  the  abdominal  muscles  have  been  employed, 
perhaps,  with  each  contraction,  though  the  presenting  part  does 
not  descend  the  birth-canal.  Suddenly  there  is  a  sharp,  excruci- 
ating, lancinating  pain  ;  the  woman  may  cry  out  that  something 
has  happened  to  her ;  the  uterine  contractions  cease,  blood  flows 
from  the  vagina,  perhaps  in  alarming  quantities,  and  the  patient 
presents  every  evidence  of  shock.  On  making  a  vaginal  ex- 
amination the  physician  finds  that  the  presenting  part  has  re- 
ceded ;  hitherto  easily  reached,  perhaps  at  the  very  outlet  of  the 
pelvis,  it  may  be  altogether  inaccessible,  and  on  passing  the 
hand  into  the  uterine  cavity  the  rent  may  be  felt,  or  intestines 
may  be  found  within  the  uterus  and  protruding  from  the  os.  On 
abdominal  palpation  the  upper  uterine  segment  may  be  felt  firmly 
contracted  to  the  size  of  the  uterus  after  labor,  and  the  child's  body 
may  be  easily  detected  in  the  abdominal  cavity  alongside  of  it. 

If  the  rupture  of  the  womb  is  not  complete,  or  is  not  large,  it 
may  not  be  discovered  until  the  child  is  born,  and  may  never  be 
suspected  at  all  unless  the  woman  develops  septic  peritonitis 
after  labor  or  discharges  ascitic  fluid  from  the  uterus.  There 
may  be  no  pain  at  the  time  of  rupture,  no  hemorrhage,  no  abnor- 
mality of  uterine  contractions.  Even  with  .  a  complete  tear  of 
large  dimensions  and  escape  of  the  child  into  the  peritoneal 
cavity  there  is  occasionally  an  astonishing  absence  of  symptoms. 
I  have  seen  a  case  in  which  the  child  passed  into  the  abdominal 
cavity  twenty-four  hours  before  I  was  summoned,  and  yet  there 
was  no  alarming  symptom  of  any  kind  until  suddenly,  at  the  end 
of  twenty-four  hours,  the  signs  of  virulent  septic  peritonitis 
appeared.  In  another  case  in  which  I  opened  the  abdomen  a 
month  after  labor  for  what  was  thought  to  be  an  intraperitoneal 
abscess,  the  fundus  uteri  was  found  ruptured  from  tube  to  tube, 
the  rent  being  shut  off  from  the  general  abdominal  cavity  by 
exudate,  which  was  undergoing  suppuration.  The  accident  of 
labor  most  commonly  mistaken  for  ruptured  uterus  is  premature 
detachment  of  a  normally  situated  placenta.  The  distinction 
between  the  two  should  be  made  easily  by  attention  to  the  fol- 
lowing differences  in  symptoms : 


Rupture  of  the  Uterus. 
Occurs  late  in  labor. 

Membranes  ruptured.  Uterus  diminished 
in  size  by  evacuation  of  some  or  all 
of  its  contents  into  the  abdominal 
cavity. 

Recession  of  presenting  part. 

Discharge  of  blood  from  vagina. 

Exploration  of  the  interior  of  the  womb 
easy,  and  rent  accessible  to  touch. 


Accidental  Hemorrhage. 

Occurs  before  labor  or  early  in  the  first 
stage. 

Membranes  unruptured.  Uterus  dis- 
tended, perhaps  irregularly  in  retro- 
placental  effusions. 

Position  of  presenting  part  unchanged. 
No  external  bleeding  in  the  concealed 

variety. 
Exploration  of  the  interior  of  the  wromb 

impossible. 


LABOR  COMPLICATED  B  Y  ACCIDENTS  AND  DISEASES.     599 

As  the  placenta  is  often  detached  when  the  uterus  ruptures, 
and  as  it  may  prolapse  in  front  of  the  child,  a  ruptured  uterus 
may  be  mistaken  for  placenta  praevia. 

If  the  physician  should  have  reason  to  suspect  that  the  uterus 
is  ruptured  during  labor,  he  should  extract  the  child  without 
delay  and  should  then  explore  the  uterine  cavity,  preferably  under 
anesthesia,  from  top  to  bottom.  By  unvarying  adherence  to 
this  rule  he  will  not  be  guilty  of  the  serious  fault  of  overlooking 
a  ruptured  womb  with  few  symptoms  until  septic  peritonitis 
occurs  and  all  treatment  is  unavailing,  or  until  the  bleeding, 
internal  or  external,  is  so  profuse  that  the  patient  can  not  be 
revived. 

The  symptoms  during  the  puerperium  indicative  of  a  ruptured 
womb  in  labor  are  :  septic  peritonitis,  profuse  uterine  hydrorrhea, 
secondary  hemorrhage  (as  late  possibly  as  the  twelfth  day),  and 
prolapse  of  the  intestines.  The  last  is  the  only  positive  sign,  unless, 
on  the  occurrence  of  the  others,  a  digital  or  instrumental  examina- 
tion of  the  uterine  cavity  reveals  the  rent. 

Prognosis. — The  prognosis  of  ruptured  uterus  depends  upon 
the  site,  extent,  and  degree  of  the  tear,  and  upon  its  treatment. 
In  ten  cases  of  rupture  of  the  anterior  wall  in  the  Berlin  Mater- 
nity every  one  ended  fatally,  and  in  three  ruptures  at  the  fundus 
the  result  was  the  same.^  Incomplete  ruptures  are  not  so  fatal 
as  those  in  which  the  peritoneum  is  also  involved,  and  the  result 
depends  somewhat  upon  the  escape  of  meconium,  liquor  amnii, 
blood,  placenta,  and  fetus  into  the  peritoneal  cavity.  Before  the 
advent  of  asepsis  and  the  improvement  in  the  technic  of  abdom- 
inal surgery  the  mortality  of  ruptured  uterus  averaged  about  90 
per  cent.  Of  late  years  the  mortality  has  been  much  reduced.  In 
60  cases  of  complete  rupture  without  active  treatment  the  mortality 
was  78.8  per  cent.,  in  70  cases  treated  by  irrigation  and  drainage 
the  mortality  was  64  per  cent.,  and  in  193  cases  treated  by  ab- 
dominal section  the  mortality  was  only  55.3  per  cent.^  In  about 
one-half  the  fatal  cases  death  occurs  within  the  first  twenty-four 
hours.  The  great  majority  of  the  remainder  die  within  three  days. 
In  some  fatal  cases,  however,  death  occurs  as  late  as  the  tenth  or 
fourteenth  day.  The  causes  of  death,  in  the  order  of  their  fre- 
quency, are  sepsis,  hemorrhage,  and  shock.  The  mortality  of 
the  infants  is  usually  over  90  per  cent.  In  the  80  cases  from  the 
Berlin  Maternity  10  children  were  saved,  but  this  is  an  unusually 
large  proportion.  If  the  woman  recovers  from  the  rupture,  she 
runs  a  great  risk  of  a  repeated  rupture  in  a  subsequent  pregnancy 

^  I  have  performed  hysterectomy  for  a  complete  rupture  of  the  uterus  across  the 
fundus,  with  success,  in  one  case. 

2  Schultz,  "  Internat.  med.  Rundsch.,"  Jan.  10,  1892. 


6oO      .  THE  PATHOLOGY  OF  LABOR. 

and  labor.  There  are  cases  on  record,  however,  of  women  safely 
delivered  in  a  subsequent  labor.  Couvelaire,^  in  17  women  who 
had  had  a  ruptured  uterus  and  again  become  pregnant,  reports 
9  cases  of  repeated  rupture,  with  6  deaths. 

Treatment. — The  preventive  treatment  of  uterine  rupture  con- 
sists in  obviating,  in  time,  the  obstructions  in  labor  that  predis- 
pose to  the  accident. 

If  a  woman  has  had  a  ruptured  uterus  and  becomes  pregnant 
again,  she  should  be  delivered  by  Cesarean  section  before  she  falls 
in  labor. 

The  treatment  of  the  rupture  itself  differs  as  the  rent  is  com- 
plete or  incomplete,  as  its  situation  admits  of  good  drainage  or 
otherwise,  and  it  depends  greatly  upon  the  escape  of  foreign 
matter  into  the  peritoneal  cavity.  The  first  care  of  the  physician 
must  be  to  extract  the  child  and  to  control  the  hemorrhage.  If 
the  child  has  escaped  into  the  abdominal  cavity,  no  effort  should 
be  made  to  extract  it  by  the  natural  passages,  but  it  should  be 
removed  through  an  abdominal  incision.  If  the  rent  is  small, 
and  the  child  has  only  in  part  passed  from  the  uterine  cavity,  it 
should  be  delivered  rapidly  by  version,  the  application  of  forceps, 
or  by  craniotomy.  The  last  is  to  be  preferred.  The  placenta 
may  be  removed  by  the  vagina,  even  though  it  has  passed  into 
the  abdominal  cavity  ;  but  if  difficulty  is  experienced  in  finding  it, 
if  the  cord  should  break  off  by  the  efforts  to  pull  the  placenta 
through  the  rent,  or  if  the  placenta  lies  hidden  under  the  perito- 
neum stripped  off  the  womb,  its  extraction  should  be  postponed 
until  the  abdomen  is  opened.  In  an  incomplete  tear  it  is  sufficient 
to  pack  the  rent  with  iodoform  gauze,  in  order  to  control  hemor- 
rhage and  to  secure  good  drainage.  This  may  be  preceded  by 
irrigation,  which  may  be  repeated  with  advantage  when  it  becomes 
necessary  to  renew^  the  gauze  packing.  If  the  rent  is  complete, 
but  small,  and  situated  low  down  upon  the  posterior  wall ;  if  there 
has  been  little,  if  any,  foreign  matter  injected  into  the  peritoneal 
cavity,  the  same  treatment  will  suffice  ;  but  if  the  tear  is  exten- 
sive, if  considerable  blood  has  passed  into  the  peritoneal  cavity, 
and,  all  the  more,  if  the  peritoneum  has  become  contaminated  by 
the  entrance  of  liquor  amnii,  of  the  placenta,  or  of  the  child  itself, 
an  abdominal  section  will  be  necessary.  With  the  abdomen  open 
a  decision  must  be  made  between  several  plans  of  procedure. 
Usually,  it  is  best  to  amputate  the  womb,  if  possible,  below  the 
site  of  the  tear.  Occasionally,  if  the  wound  is  not  too  ragged 
and  can  be  thoroughly  approximated,  it  will  be  sufficient  to  unite 
it  with  deep  and  superficial  sutures,  care  being  taken  to  cover 
over  the  line  of  rupture  with  inverted  peritoneum.  In  case  the 
peritoneum  is  stripped  off  the  womb  for  a  considerable  distance, 

1  "Rev.  prat.  d'Obstet.  et  de  paed.,"  Oct. -Dec,  1903. 


LABOR  COMPLICATED  BY  ACCIDENTS  AND  DISEASES.     6oi 

and  it  is  impossible  to  secure  a  good  stump,  a  flap  of  peritoneum 
may  be  dissected  ofif  the  uninjured  side  of  the  womb  and  used  to 
cover  over  the  upper  portion  of  the  stump  and  its  denuded  sur- 
face ;  or  it  may  be  preferable  to  do  a  panhysterectomy,  sewing 
up  the  opening  left  in  the  vagina  in  such  a  manner  as  to  cover 
any  denuded  surfaces.  If  the  tear  is  on  the  anterior  wall,  or  at 
the  fundus,  an  abdominal  section  is  necessary.  On  opening  the 
abdomen  one  of  the  procedures  detailed  above  may  be  adopted, 
or  it  may  be  possible,  as  it  was  in  one  of  Leopold's  cases,  to  splint 
the  womb  by  gauze  packing  in  the  pelvis  and  abdomen,  so  as  to 
bring  the  torn  surfaces  firmly  together. 

In  an  abdominal  section  for  ruptured  uterus  the  toilet  of  the 
peritoneal  cavity  must  be  made,  of  course,  with  the  greatest  care. 
It  is  better,  if  possible,  to  cleanse  the  abdominal  cavity  with  pads 
of  gauze,  rather  than  to  flush  it  with  water  ;  but  the  latter  plan 
is  sometimes  necessary  to  remove  small  clots  of  blood  scattered 
throughout  coils  of  intestines  or  hidden  in  the  depths  of  the  pelvis. 
Resection  of  the  intestines  and  intestinal  anastomosis  is  occasion- 
ally required.  In  one  of  my  cases  the  medical  attendants  had 
pufled  off  both  arms  of  the  child  in  attempts  to  extract  it,  and  then 
through  a  rupture  of  the  lower  uterine  segment  had  pulled  two 
feet  of  ileum  loose  from  its  attachment  to  the  mesentery. 

Injuries  to  the  Cervix. — The  cervix  is  injured  to  some  extent 
in  every  labor,  but  serious  tears,  that  cause  at  the  time  profuse 
hemorrhage  and  give  rise  to  symptoms  subsequently,  are  com- 
paratively rare.  The  causes  of  serious  injuries  to  the  cervix  are  : 
precipitate  delivery,  premature  rupture  of  the  membranes,  forcible 
extraction  of  the  child  by  the  forceps  or  after  version  before  the 
OS  is  thoroughly  dilated,  incarceration  of  the  anterior  lip  of  the 
cervix  between  the  child's  head  and  the  pelvis,  and  abnormal 
rigidity  of  the  cervix.  The  tear  is  usually  bilateral,  occasionally 
unilateral,  in  rare  cases  multiple,  and  in  one  instance  under  the 
writer's  observation  directly  in  the  anterior  median  line.  In  rare 
instances  the  tear,  instead  of  being  longitudinal,  may  be  circular, 
and  in  consequence  the  vaginal  portion  of  the  cervix  may  be 
completely  torn  off  from  the  womb. 

The  cervical  tear  manifests  itself  immediately  after  delivery  of 
the  child,  usually  by  some  hemorrhage,  occasionally  by  profuse 
and  dangerous  bleeding.  A  digital  examination  of  the  vagina 
directly  after  the  extraction  or  expression  of  the  jflacenta  informs 
the  physician  of  the  condition  of  the  cervix,  and,  if  the  cervix  is 
inspected  through  a  speculum  during  the  pucrj)crium,  a  torn 
cervix  that  needs  attention  should  never  be  overlooked. 

The  hemorrhage  from  a  torn  cervix  directly  after  labor  may 
be  controlled  in  two  ways.  First,  by  ligatures,  which  are  per- 
fectly certain  to  effect  the  desired  result,  but  which  are  not  ahvavs 


602 


THE  PATHOLOGY  OF  LABOR. 


easy  to  insert,  and  which  increase  the  danger  of  septic  infection, 
unless  the  attendant  possesses  gynecological  skill  and  has  the 
necessary  equipment  for  operating  in  a  perfectly  aseptic  manner. 


Fig.  475. — Spontaneous  repair  of  a  stellate  laceration  of  the  cervix, 
life,  three  months  after  labor. 


Drawn  from 


The  easiest,  and  on  the  whole  safest,  plan  for  checking  the  hem- 
orrhage from  a  torn  cervix  in  general  practice  is  to  insert  a 
tampon  in  the  form  of  a  half  ring  in  the  lateral  vault  of  the 
vagina.  The  best  tampon  material  is  iodoform  or  sterile  gauze. 
I  have  never  kno^wn  this  device  to  fail  in  checking  hemorrhage 
from  a  torn  cervix. 

It  is  a  moot  question  whether  a  torn  cer\ax  should  always 
be  repaired  in  the  early  puerperium.  In  general  practice,  the 
following  arguments  are  usually  advanced  against  the  primary  re- 
pair of  the  cervix:  Stitches  placed  in  a  relaxed  cervix  directly  after 
labor  will  probably  not  be  tight  enough  at  the  end  of  twenty-four 
hours  to  close  the  wound.  To  place  them  properly  requires 
considerable  skill,  and  necessitates  dragging  the  cervix  into  view 
by  bullet  forceps.  The  necessary  instruments  are  rarely  to  be 
found  in  the  general  practitioner's  armamentarium,  and  many 
lacerated  cervices  heal  spontaneously,  if  the  woman  is  kept  quiet 
on  her  back  in  bed  for  a  sufficient  length  of  time,  without  \aginal 
douching  or  other  interference  that  could  disturb  the  approxima- 
tion of  the  edges  of  the  tear.  In  a  well-equipped  clinic  or  in  the 
private  practice  of  a  specialist,  on  the  contrary ,  the  repair  of  lacerated 
cervices  during  the  puerperium  is  recommended.     It  is  the  author's 


PLATE   12. 


Lacerations  of  tlie  cervix  :  i,  'r\v(j  weeks  after  lal>or  ;  2,  one  week  after  labor  ; 
3,  four  days  after  labor;  4,  iinniodiately  after  labor.  The  degree  of  iinobition 
shown  in  No.  1   should  be  awaited  before  repairing  the  cervi.x. 


LABOR    COMPLICATED   BY  ACCIDENTS  AND  DISEASES.    603 

practice.  It  is  better  to  wait  five  to  seven  days  after  labor.  Clin- 
ical experience  has  shown  that  there  is  less  danger  of  infection  in  the 
intermediate  than  in  the  primary  operation. 

Circular  Detachment  of  the  Vaginal  Portion  of  the  Cervix  Dur= 
ing  Labor. — Rarely  the  whole  vaginal  portion  of  the  cervix  is 
torn  olf  from  the  womb  and  emerges  from  the  vulva  in  front 
of  the  child's  head.  This  accident  may  be  the  result  of  extreme 
rigidity  of  the  cervix,  or   of  the   cervix  being-  caught  between 


Figs.  476  and  477. — Author's  cases  of  annular  tktachment  of  tlie  cervix. 

the  walls  of  the  pelvis  and  the  child's  head,  if  the  former  is  con- 
tracted or  the  latter  is  very  large.  I  have  seen  three  cases,  all 
due  to  extreme  rigidity  of  the  cervix  (Figs.  476,  477).  In  each 
case  the  woman  was  an  elderly  primipara,  and  was  quite  obese. 
One  of  them  was  delivered  a  year  later  unfler  my  charge  without 


604  THE   PATHOLOGY  OF  LABOR. 

difficulty.  In  one  case  (Fig.  476)  there  was  a  narrow  tab  of  cer- 
vical tissue  left  in  the  median  line  posteriorly.  Although  the 
injury  at  first  sight  appears  serious,  there  is  no  hemorrhage,  nor 
is  the  puerperal  convalescence  disturbed.  This  accident  could 
almost  always  be  averted  by  multiple  incisions  in  the  cervix. 

Lacerations  of  the  Vagina. — The  vagina  may  be  torn  by  the 
insertion  of  the  hand,  by  the  rapid  extraction  of  the  child,  by 
the  extension  of  tears  from  the  cervix,  by  the  propulsion  of  the 
child's  body  against  the  posterior  wall  without  sufficient  deflec- 
tion forward  to  facilitate  its  escape  from  the  vulvar  orifice,  and, 
most  frequently  of  all,  by  the  blade  of  a  forceps  which  does  not 
fit  the  child's  head  properly,  or  which  is  not  used  with  sufficient 
care  as  to  the  direction  of  the  force  that  is  applied  in  the  extrac- 
tion of  the  head. 

The  tears  of  the  vagina  accompanying  a  lacerated  perineum 
or  injured  pelvic  floor  are  described  under  the  latter  heading. 

Tears  of  the  vagina  extending  from  the  cervix  involve 
usually  the  lateral  vaginal  vaults,  occasionally  opening  deep 
rents  into  the  base  of  the  broad  ligaments,  and  involving  possibly 
the  uterine  arteries  or  even  the  ureters.  The  hemorrhage  from 
these  tears  is  best  controlled  by  ligating  the  bleeding  vessels  if 
they  can  be  found,  or  by  firmly  tamponing  the  rent  if  it  is  impos- 
sible to  locate  the  bleeding  points.  Drainage  must  be  secured 
by  gauze  packing,  and,  when  the  wound  begins  to  granulate, 
daily  washing  with  sterile  water  should  be  employed.  The  tears 
of  the  posterior  vaginal  wall  sometimes  result  in  perforations  of 
the  rectum,  and  in  consequence  a  portion  of  the  child,  as  an 
extremity,  may  emerge  from  the  anus.  ^  These  perforations 
should  be  repaired  immediately  after  labor  by  buried  running 
sutures  of  catgut  and  interrupted  stitches  of  silkworm  gut. 

The  tears  of  the  anterior  vaginal  wall  made  by  a  forceps- 
blade  are  almost  always  clean-cut,  and  are  apt  to  bleed  pro- 
fusely. They  should  be  closed  by  a  running  catgut  suture. 
In  one  case  under  my  care  the  hemorrhage  was  so  profuse  that 
it  was  impossible  to  see  the  wound  at  all,  and  there  was  danger 
of  the  woman  bleeding  to  death  while  I  attempted  to  sew  it  up. 
After  several  abortive  attempts  the  wound  was  successfully 
repaired  without  further  bleeding  by  pushing  a  tampon  into  the 
vagina  and  following  the  tampon  as  it  was  pushed  up  along  the 
course  of  the  wound  with  a  needle  and  thread,  until  the  upper 
end  of  the  tear  was  reached. 

Lacerations  of  the  anterior  and  posterior  vaginal  vaults  penetrat- 
ing to  the  peritoneal  cavity  are  usually  associated  with  rupture  of 
the  uterus.    They  are  to  be  treated  by  gauze  packing  and  drainage. 

1  Piering,  "  Centralblatt  f.  Gyn.,"  No.  48,  1891.  See  also  Engelmann,  ibid.. 
No.  46,  1900. 


LABOR    COMPLICATED   BY  ACCIDENTS  AND  DISEASES.    605 


Figs.  478,  479,  and  480. 


-Lacerations  and  abrasions  of  the  vestibule  and  vaginal 
entrance  (Bar). 


6o6 


THE   PATHOLOGY  OF  LABOR. 


Figs.  481,  482,  483.— Lacerations  and  abrasions  of  the  vestibule  and 
vaginal  entrance  (Bar). 


LABOR    COMPLICATED   BY  ACCIDENTS  AND  DISEASES.    607 

Lacerations  and  Abrasions  of  the  Vulva,  of  the  Vestibule,  and  of 
the  Vaginal  Entrance. — The  most  frequent  site  for  injuries  in  this 
region  is  the  upper  portion  of  the  vestibule  and  the  tissues  on  one 
side  of  the  chtoris  or  of  the  urethra.  Tears  in  this  situation  bleed 
profusely,  and  they  are  so  common  that  it  is  a  valuable  rule  of 
practice  always  to  look  in  this  region  for  injury  when  there  is 
a  hemorrhage  from  the  vagina  after  labor  with  a  well -contracted 
womb.  The  bleeding  points  are  in  plain  sight,  and  the  hemor- 
rhage is  easily  controlled  by  a  stitch  or  two,  deep  enough  to 
undersew  the  whole  depth  of  the  tear.  A  catheter  should  be 
placed  in  the  urethra  to  guard  against  occluding  it.  In  abrasions 
of  the  labia  and  of  the  vestibule,  care  must  be  taken  that  the  raw 
surfaces  shall  not  unite,  causing  atresia  of  the  vagina.  This  can 
easily  be  prevented  by  laying  oiled  lint  over  the  raw  surfaces,  and 
by  the  use  of  douches. 


Figs.  484  and  485. — Perforations  and  lacerations  of  the  nymphs  (Bar). 


Lacerations  of  the  Perineum. — The  causes  and  prex'cntive  treat- 
ment of  lacerations  of  the  perineum  are  considered  elsewhere. 
The  extent,  situation,  and  recognition  of  the  injury  arc  dealt  with 
in  this  section.  The  commonest  form  of  torn  perineum  is  shown 
in  Plate  2  and  in  Figs.  492  and  493.  It  may  be  seen  that  the 
tear  rarely  involves  the  perineum  alone,  but  usually  extends  up 
the  posterior  wall  of  the  vagina,  on  one  or  both  sides  of  the  posterior 
column.  Experience  teaches,  moreover,  that  lacerations  of  the 
perineum  alone,  when  they  do  occur,  have  very  little  effect  upon  the 
patient's  after-condition,  even  though  they  reach  to  the  anus  and 
sever  the  transverse  perineal  muscle  (see  Figs.  496,  497).     The 


6o8 


THE   PATHOLOGY  OF  LABOR. 


greatest  care  should  be  exercised,  therefore,  to  ascertain  the  extent 
of  the  injury  to  the  vagina  which  is  associated  with  the  tear  of  the 
perineum.  This  is  best  done  by  placing  the  woman  in  the  dorsal 
position  across  the  bed  or  on  a  table,  with  her  thighs  well  flexed 
upon  the  abdomen  and  widely  separated,  and  with  the  buttocks 
projecting  beyond  the  edge  of  the  bed  or  table.  A  nurse  or  other 
assistant,  whose  hands  are  protected  by  sterile  gloves,  holds  the 
labia  apart,  and  the  physician  cleanses  the  torn  surface  of  the  poste- 


Figs.  486,  487,  488,  489. — Varieties  of  central  tear  of  the  perineum 
("  Precis  d'Obstetrique"). 


rior  wall  of  the  vagina  with  pledgets  of  sterile  cotton.  In  this  way 
the  exact  nature  and  the  extent  of  the  injury  may  be  seen.  If  the 
tear  is  complete, — that  is,  through  the  sphincter, — the  fact  should 
be  evident  on  inspection.  If  there  is  any  doubt  about  it,  the 
forefinger  of  the  left  hand  is  inserted  in  the  anus,  the  thumb  in 
the  vagina,  and  the  thickness  of  tissues  between,  or  their  absence, 
can  thus  be  appreciated.  It  is  a  serious  error  to  overlook  a  com- 
plete  tear.     Many  suits  for   damages   have   been  based  on   this 


PLATE   13. 


/y^ 


-  "^  $t 


^^^    f^/.'J' 


LABOR    COMPLICATED  BY  ACCIDENTS  AND  DISEASES.     609 

ground.  A  central  tear  or  perforation  of  the  puerperium  presents 
the  appearance  represented  in  Figs.  486-489.  A  probe  passed  into 
the  vagina  through  the  perineal  wound  shows  the  nature  of  the 
injury.  The  laceration  may  be  immediately  repaired;  but  the 
author  prefers  repairing  all  the  injuries  of  childbirth  at  the  end  of 
five  to  seven  days  after  delivery,  making  a  formal  plastic  operation. 
After  trying  the  different  periods  for  repair  work,  from  a  few 
minutes  after  labor  to  the  end  of  the  puerperium,  in  series  of 
many  hundreds  of  cases,  the  end  of  the  first  week  has  been  found 
the  best  time.  Immediately  after  labor  the  tissues  are  bruised  and 
edematous;  the  bloody  discharge  is  profuse  and  embarrassing;  it 


Fig.  490. — Testing  the  thickness  of  tissues  between  the  rectum  and  the  vagina. 

is  impossible  to  make  an  accurate  diagnosis  of  the  extent  of  the 
injury  and  it  is  unwise  to  repair  the  cervix.  Repairs  of  the  peri- 
neum and  pelvic  floor  at  this  time  are  often  failures  and  must  be 
done  again.  By  waiting  a  week  the  tissues  are  in  more  favorable 
condition  for  good  union,  and  it  is  possible  to  make  a  careful  ex- 
amination of  the  whole  genital  canal  and  to  repair  every  one  of 
the  injuries  of  childbirth.  If  the  woman  is  infected,  has  kidney 
disease,  or  has  had  a  serious  hemorrhage,  it  is  desirable  to  wait 
several  weeks.  The  operation  should  be  performed  on  a  suitable 
table,  with  sufficient  assistants  and  implements,  and  under  anes- 
thesia. 


6io 


THE   PATHOLOGY  OF  LABOR. 


Injuries  of  the  Anterior  Vaginal  Wall. — There  is  quite  fre- 
quently a  submucous  laceration  of  the  muscle  and  fascia  of  the  uro- 
genital trigonum  (Waldeyer)  in  the  anterior  sulci,  usually  most 
marked  in  the  left.     This  muscle  is  the  main  support  of  the  lower 


-^^ 


Fig.  491. — Abrasions  of  the  vulva  and 
lacerations  of  the  vaginal  sulci  (Bar). 


Fig.  492. — Deep  laceration  of  the 
perineum  and  of  one  sulcus ;  splits  in 
the  vaginal  mucous  membrane  (Bar). 


f'k 


Fig.  493. — Laceration  of  the  perineum 
and  of  one  sulcus  (Bar).     • 


Fig.  494. — Laceration  of  the  peri- 
neum and  of  the  sulci ;  abrasions  of 
the  vulva  (Bar). 


anterior  vaginal  wall.  Its  laceration  allows  the  anterior  wall  to 
drop  backward  and  outward.  The  constant  drag  of  this  prolapsed 
portion  of  the  wall  upon  the  structures  above  is  one  of  the  factors 
that  causes  a  cystocele  in  the  course  of  time.     The  injury  can  be 


Plate  14. 


Complete  tears  of  the  perineum  (painted  from  life  a  few  hours  after  the  injury) : 
I,  Tear  involving  some  of  the  fibers  of  the  sphincter,  but  not  all  ;  2,  median  ct)m- 
plete  tear,  with  abrasion  of  the  vulva,  and  two  large  hemorrhoidal  veins  exposed, 
one  on  either  side  ;  3.  complete  median  tear,  with  sphincter  muscle  hidden  by  three 
larpjeTiemonhoids;  4,  lateral  complete  tear,  involving  left  vaginal  sulcus. 


LABOR    COMPLICATED   BY  ACCIDENTS  AND   DISEASES.    6l  I 

recognized  by  pressing  a  finger  upward  against  the  pubic  bone. 
The  presence  or  absence  of  the  muscle  is  easily  determined. 


^(^rmfp^ 


Fig.  495. — Laceration  of  the  vaginal  sulci  without  a  tear  of  the  perineum 
proper  (Bar). 


^r 


-    M 


Figs.  496  and  497. — Lacerations  of  the  perineum  without  involvement  of  the 
pelvic  floor.  Such  tears  would  not  affect  the  woman's  health  or  comfort  subse- 
quently (IJarj. 

Inversion  of  the  uterus  is  the  rarest  of  all  the  accidents 
to  a  parturient  woman.  In  the  Vienna  jNIaternity,  from  1849  to 
1878,  in  more  than  250,000  labors,  there  was  not  a  case.  In  the 
Rotunda  Hospital,  in  Dublin,  there  were  190,000  labors,  with  only 
one  inversion  of  the  womb.  Winckel  did  not  see  a  case  in  20,000 
labors.     My  own  experience  amounts  to  six  cases — fi^•e  complete 


6l2 


THE  PATHOLOGY  OF  LABOR. 


and  one  partial.^  In  general  practice,  especially  among  the  poorer 
classes,  inversion  of  the  womb  is  not  so  rare.  The  accident  happens 
with  equal  frequency  before  and  after  the  delivery  of  the  placenta. 
It  is  commoner  in  young  primiparse  than  in  multiparse.  It  is 
reported  to  have  occurred  on  the  third,  fifth,  sixth,  and  fifteenth 
day  of  the  puerperium,^  and  has  recurred  on  the  fourth  day.^ 
The  inversion  may  be  partial  or  complete,  the  former  when  the 
fundus  simply  protrudes  into  the  uterine  cavity,  the  latter  when  the 
womb  is  turned  completely  inside  out.  In  a  complete  inversion 
the  fundus  is  just  within  the  vulva;  the  cavity  of  the  womb  is  formed 
by  the  peritoneal  surface,  the  orifice  looking  upward  into  the  peri- 
toneal cavity.  From  this  cavity  the  tubes  and  the- ovarian  and 
round  ligaments  run  upward ;  the  ovaries  are  usually  above  and  to 
either  side  of  the  orifice.  Inversion  of  the  womb  may  be  associ- 
ated with  inversion  of  the  vagina.  In  such  a  case  the  inverted 
womb  is  also  prolapsed. 

Causes. — Inversion  of  the  uter- 
us may  occur  spontaneously.  In 
the  so-called  paralysis  of  the  pla- 
cental site, — a  condition  in  which 
this  portion  of  the  uterine  wall  be- 
comes so  relaxed  and  flabby  that 
it  sags  down  into  the  uterine  cav- 
ity,^the  projecting  portion  of  the 
wall,  it  is  said,  is  seized  upon  by 
the  remainder  of  the  uterine  mus- 
cle as  a  foreign  body,  and  de- 
pressed further  and  further  toward 
the  cervical  canal,  as  a  polypoid 
tumor  might  be  expelled.  The 
explanation,  however,  is  strained. 
A  contraction  of  the  uterine  mus- 
cle under  these  circumstances 
would  reinvert  the  womb.  A 
much  more  plausible  explanation 
for  spontaneous  inversion  is  found 
in  an  adherent  placenta  and  en- 
tire relaxation  of  the  uterine  walls. 
In  this  condition  of  affairs  the  mere  weight  of  the  placenta  is 

^  Three  cases  were  seen  directly  after  labor  ;  two  were  reduced  by  taxis ;  the  other 
spontaneously.  One  case  of  complete  inversion  was  reduced  five  days  after  labor  by 
taxis  ;  another  three  months  after  labor  by  the  author's  operation.  Tlie  sixth  case  of 
inversion  was  due  to  a  myomatous  polyp  at  the  fundus.  It  was  complete,  but  was 
easily  reduced  by  taxis  after  the  removal  of  the  polyp. 

'■'Lepage,  "  Comp.  rend.  Soc.  d'Obstet.  de  Gyn.  et  de  Pasdiatr.,"  1905,  p.  213. 

*  Fisher,  "Br.  Med.  Jour.,"  1896,  vol.  ii,  p.  1178;  and  Burton,  "Am.  Jour,  of 
Obstet.,"  vol.  xxxvi,  p.  548  ;  "  v.  Winckel's  Handbuch  der  Geburtshulfe,"  III.  Band, 
II.  Theil,  1906,  p.  162. 


Fig.  498. — Pardal  inversion  of  the 
uterus. 


LABOR    COMPLICATED  BY  ACCIDENTS  AND  DISEASES.    613 

enough  to  drag  the  fundus  down  into  the  uterine  cavity.  A  most 
favorable  predisposing  cause  is  furnished  by  a  complete  inertia 
uteri  at  the  close  of  the  second  stage  of  labor.  The  expressive 
force  of  the  abdominal  muscles  not  only  expels  the  child's  body, 
but  drives  down  the  uterus  after  it.  Inversion  of  the  uterus 
may  be  most  frequently  explained  by  traction  on  the  cord  in 
the  third  stage  of  labor,  when  the  placenta  is  adherent.  It  may 
occur  in  consequence  of  a  short  cord  pulhng  upon  the  placenta 


P'ig.  4g9. — Complete  inversion  with  prolaps(  4,  Mons  veneris;  B,  labia 
majora;  C,  labia  minora  ;  /?,  clitous  ,  ji,  unnary  meatus  ,  /",  external  anterior  bor- 
der of  the  vagina ;  G,  external  border  of  the  os  uteri ;  H,  the  internal  surface  of  the 
uterus,  now  external  (Boivin  and  Dug6s). 

during  labor.  It  has  followed  precipitate  birth  in  the  erect  posture, 
straining  the  abdominal  muscles  to  pass  urine  or  to  expel  the  pla- 
centa, the  woman  sitting  erect,  violent  coughing  or  vomiting,  and 
carrying  a  weight  up  stairs  directly  after  deli\ery.  In  a  case  under 
my  observation  the  cord  was  wound  three  times  around  the  child's 
neck.  It  is  sometimes  due  to  too  vigorous  compression  of  the 
fundus  in  efforts  to  express  the  placenta,  and  I  ha\-c  seen  it  occur  on 
one  occasion  in  an  effort  to  extract  an  adherent  ])laccnta,  in  which 
the  hand  and  the  placenta  grasi)ed  within  it  acted  like  the  ])iston 
of  a  syringe  and  drew  the  fundus  down  into  the  uterine  cavity. 


6i4 


THE  PATHOLOGY  OF  LABOR. 


Another  case  under  my  observation  appeared  to  be  due  to  the  uni- 
versal adherence  of  the  membranes  after  the  detachment  of  the 
placenta.  The  weight  of  the  latter,  dragging  on  the  uterus  by  the 
membranes,  turned  it  inside  out.  A  necessary  predisposition  to 
inversion  of  the  womb  is  relaxation  of  its  walls.  If  the  uterus  is 
firmly  contracted,  the  accident  cannot  occur. 

Symptoms. — Inversion  occurs  suddenly,  and  is  usually  asso- 
ciated with  profound  shock,  and  often  xdx\x  some  hemorrhage. 
The  patient  at  once  passes  into  a  most  alarming  condition,  that 
can  scarcely  fail  to  attract  any  one's  attention.  The  only  causes 
for  her  condition  would  be  hemorrhage,  rupture  of  the  uterus. 


P'ig.  500. — Partial  inversion  of  the  uterus. 

syncope,  or  inversion.  An  immediate  vaginal  examination  should 
always  be  made,  whereupon  the  nature  of  the  trouble  should  mani- 
fest itself  at  once.  The  inverted  uterus  is  found  filling  up  the 
vagina,  and  almost  projecting  from  the  vulva.  By  abdominal 
palpation  one  notes  the  absence  of  uterine  tumor  in  the  hypo- 
gastrium,  and  can  detect,  moreover,  a  groove  or  slit  running 
across  what  remains  of  the  cervix.  If  necessary^  a  rectal  exam- 
ination would  reveal  the  absence  of  the  womb  and  the  depression 
in  the  cervix  where  it  is  inverted  even  more  plainly  than  these 
signs  could  be  detected  by  abdominal  palpation  ;  but  a  rectal  ex- 
amination should  scarcely  ever  be  necessary'.  The  cervix  itself 
remains  uninverted  as  a  collar  about  the  lower  uterine  segment. 
Between  the  cervix  and  the  uterine  wall  a  sound  or  the  finger 
may  be  inserted  a  little  way,  but  it  is  impossible  to  find  a  uterine 
cavity.     This  fact  should  always  make  the  distinction  between  an 


LABOR  COMPLICATED  BY  ACCIDENTS  AND  DISEASES.    615 


Fig.  501. — Inversion  of  the  uterus  and  the  author's  operation  for  its  correction  : 
I,  Complete  inversion,  3  months  after  labor;  2,  discission  of  the  cervix  through  its 
entire  length,  supravaginal  as  well  as  infravaginal  portion  ;  3,  inversion  corrected  and 
sutures  introduced  ;  4,  sutures  fastened. 


6i6 


THE   PATHOLOGY  OF  LABOR. 


inverted  womb  and  a  fibroid  polypus  or  other  tumor  projecting 
from  the  uterine  cavity.  Mistakes,  however,  of  the  most  serious 
character  have  been  made  in  this  connection.  In  one  case  the 
inverted  womb  was  torn  away  in  the  behef  that  it  was  a  fibroid 
tumor,  and  in  another  the  wire  of  an  ecraseur  was  adjusted  about 
an  inverted  womb,  and  was  about  to  be  screwed  tight,  when  the 
true  character  of  the  mass  in  the  vagina  was  detected. 


Fig.  502. — Inversion  of  uterus  showing  necessity  of  pressure  forward  in  taxis  for  its 

reduction. 

Treatment. — Occasionally,  a  spontaneous  reduction  of  the 
inversion  occurs,  especially  when  inversion  is  partial.  This 
occurred  in  one  of  the  six  cases  under  my  observation.  If  the 
inversion  is  complete,  spontaneous  reduction  cannot  be  expected. 
If  the  placenta  is  still  attached  to  the  uterus,  it  should  be  first  re- 
movedj  and  then  pressure  exerted  with  the  fingers  upon  the  lower 


LABOR    COMPLICATED   BY  ACCIDENTS  AND  DISEASES.     617 

uterine  segment  in  a  direction  forward  and  slightly  upward.  To 
do  this,  the  hand  must  be  inserted  well  into  the  vagina  and  back 
toward  the  sacrtim,  and  the  fingers  must  then  be  directed  well  for- 
ward toward  the  anterior  abdominal  wall,  in  the  direction  of  the 
axis  of  the  superior  strait.  The  mistake  is  almost  always  made  of 
pressing  upward  against  the  sacrum,  so  that  the  efforts  to  reduce  the 
womb  may  fail  altogether,  and  a  chronic  or  permanent  inversion 
may  be  left  for  the  surgeon  to  deal  with  after  the  puerperium  is  com- 
pleted.     With  the  proper  direction  of  force  in  one's  effort  to  reduce 


Fig.  503. — I,  Complete  inversion  of  the  uterus;  2,  first  manoeuver  to  reinvert 
the  lower  uterine  segment ;  3,  second  manoeuver  to  widen  cervical  ring  and  afford 
counterpressure  by  an  assistant. 

an  inverted  uterus,  failure  ought  to  be  almost  unknown,  if  the  repo- 
sition of  the  womb  is  undertaken  at  once,  as  it  alwaj's  should  be.  If 
there  has  been  a  deep  tear  of  the  cervix,  the  best  place  to  begin  the 
reinversion  is  just  below  the  upper  margin  of  the  tear.  I  suc- 
ceeded by  this  plan  in  one  case  after  two  other  physicians  had 
failed  and  after  my  own  attempts  at  reduction  by  pressure  on 
the  lower  uterine  segment  posteriorly  had  been  futile. 


6l8  THE   PATHOLOGY  OF  LABOR. 

Strange  as  it  may  seem,  the  inversion  has  been  overlooked 
for  some  days  or  akogether  in  quite  a  large  proportion  of  the 
cases.  If  the  cervix  is  allowed  to  contract  firmly,  as  it  will  in 
a  few  hours,  the  reposition  of  the  womb  becomes  extremely 
difificult.  In  one  of  my  cases,  seen  in  consultation,  five  days 
had  elapsed  since  the  woman's  delivery.  She  had  suffered  great 
pain,  had  considerable  fever,  with  a  foul  discharge,  and  had 
a  very  rapid  pulse,  yet  no  vaginal  examination  had  been  made, 
although  the  patient  was  in  charge  of  a  professed  expert  in 
gynecology  !  The  uterus  was  completely  inverted.  Reposi- 
tion was  finally  accomplished  by  the  following  plan:  One 
hand,  made  into  a  cone  shape,  was  inserted  in  the  vagina 
and  the  finger-tips  were  pressed  steadily  against  one  side  of 
the  lower  uterine  segment,  forcing  it  into-  the  cervical  ring. 
After  steady  pressure  for  almost  an  hour,  the  cervix  yielded 
considerably.  Then  an  assistant  helped  in  the  dilatation  of 
the  cervical  ring,  in  the  manner  shown  in  figure  503,  and  at  the 
same  time  made  counterpressure  downward  upon  the  cervix. 
The  womb  was  returned  to  its  natural  position  shortly  after 
this  manoeuver  was  tried.  The  woman  recovered.  If  taxis  fails, 
the  cervix  may  be  cut  in  two  in  the  median  line  posteriorly  from 
the  external  os  to  the  lower  uterine  segment.  As  soon  as  the 
obstruction  of  the  contracted  cervical  muscle  is  removed  the 
uterus  may  be  reinverted  without  difficulty.  The  wounds  in  the 
cervix  and  vaginal  vault  are  closed  with  interrupted  sutures. 
Some  of  those  in  the  supravaginal  portion  of  the  former  may 
have  to  be  buried,  and  should  be  of  catgut.  This  operation 
has  distinct  advantages  over  those  of  Barnes,  Gaillard  Thomas, 
Browne,  and  Kiistner.  ^  The  separation .  of  the  anterior  cervical 
wall  from  the  bladder  and  its  complete  discission  may  be  more 
effectual  than  posterior  discission.^  If  it  should  be  impossible  to 
reinvert  the  uterus  after  complete  discission  of  the  cervix,  Spinelli's 
operation — dividing  the  posterior  or  anterior  uterine  wall  as  well 
as  the  cervix — may  be  tried. 

Prognosis. — The  mortality  of  inversion  of  the  womb  has 
been  extremely  high.  In  one  series  of  109  cases  there  were 
80  deaths,  and  72  of  these  within  a  few  hours  after  labor.  In 
another  series  of  54  cases  there  were  12  deaths  (Winckel).  The 
six  cases  under  my  care  recovered.  The  causes  of  death  are  : 
shock,  hemorrhage,  sepsis,  peritonitis,  and  exhaustion  from  long- 
continued  loss  of  blood. 

1  Bernard  Browne,  "  Tr.  Am.  Gyn.Soc,"  1899. 

^Oui,  "Ann.  de  Gyn.  et  d'Obstet.,"  Oct.,  1901.  Good  bibliography.  Also 
Reuben  Peterson,  "The  Conservative  Operative  Treatment  of  Chronic  Inversion  of 
the  Uterus,"  "Am.  Gyn.,"  June,  1903. 


LABOR    COMPLICATED   BY  ACCIDENTS  AND   DISEASES.     619 

Injuries  of  the  Urinary  Tract ;  Genito=urinary  Fistulee. — 

The  commonest  fistula  is  vesico-vaginal,  due  to  pressure  necro- 
sis of  the  vesico-vaginal  septum  in  a  prolonged  labor.  The 
bladder  wall  has  been  punctured  or  ruptured  by  the  blunt  hook; 
by  forcible  delivery  with  forceps,  in  cases  of  cystocele  distended 
with  urine;  by  craniotomy  instruments;  by  spicules  of  fetal 
bone;  by  unskilful  extraction  of  the  head  after  version;  by  a 
vesical  calculus  caught  between  the  fetal  head  and  the  maternal 
symphysis  and  by  rough  intravaginal  manipulations.  The  first 
symptom  to  attract  attention  is  incontinence  of  urine.  A  visual 
examination,  the  use  of  a  sound  in  the  bladder,  injections  of  col- 
ored fluid  into  the  bladder,  indagation,  and,  if  necessary,  cystos- 
cop\',  make  the  diagnosis  certain.  If  there  is  no  loss  of  sub- 
stance, the  injury  may  be  primarily  repaired.  Sometimes  the 
opening,  if  small,  is  closed  spontaneously  by  granulation  tissue. 
Usually  a  secondary  operation  is  required,  which  should  be 
performed,  if  possible,  four  to   six  weeks  after  labor. 

Rupture  of  the  symphysis  occurs  not  infrequently,'^  usually 
in  consequence  of  some  disease  within  the  joint  itself,  occasionally 
as  the  result  of  great  force  in  the  extraction  of  the  head  with  for- 
ceps or  after  version.  The  accident  may  be  recognized  at  the 
time  of  its  occurrence  by  feeling  the  bones  give  way,  or  by  actu- 
ally hearing  them  snap.  But  it  may  not  be  detected  until  the 
woman  complains  of  great  pain  in  the  symphysis,  and  of  inability 
to  sit  up  or  walk  when  she  rises  from  bed.  Not  infrequently  rup- 
ture of  the  symphysis  is  followed  by  suppuration  of  the  joint. 
The  accident  must  be  treated  by  a  firm  binder  around  the  hips, 
and  sand-bags  such  as  are  used  after  a  symphysiotomy,  and  by 
keeping  the  patient  in  bed  four  or  five  weeks.  Suturing  the  ends 
of  the  bones  with  silver  wire  may  be  required.  If  the  joint  suppu- 
rates, it  should  be  opened  as  early  as  possible  and  should  be  well 
drained.  The  prognosis  of  the  injury  is  not  serious.  Recovery 
may  be  expected  as  a  rule,  without  impairment  of  locomotion 
or  other  disagreeable  consequences,  if  the  symphysis  alone  is  in- 
jured. 

Rupture  of  the  sacro=iIiac  joints  has  the  same  causes  as 
rupture  of  the  symphysis,  and  is  often  associated  with  it.  Inflam- 
mation and  suppuration  in  these  joints  often  follow  their  injury. 
The  symptoms  in  the  puerpcrium  are,  great  pain  over  the  joints 
on  attempting  to  walk,  a  feeling  of  insecurity  in  the  pelvic  bones, 
a  wabbling  gait,  and  loss  of  power  in  one  or  both  lower  limbs,  with 
fever  if  thejoints  are  inflamed  or  suppurate.  The  only  treatment 
available  is  firm  support  of  the  pelvis  by  a  pelvic  binder,  sand-bags 

'  Ahlfeld  collected  100  cases,  to  which  number  Schauta  added  14  (Miiller's 
"Handbuch").  In  94, 149  labors  this  accident  occurred  three  times.  About  130 
cases  are  on  record.     Kayser,  "Arch.  f.  Gyn.,"  Bd.  Ixx,  II.  i,  1903. 


620  THE    PATHOLOGY  OF  LABOR. 

alongside  the  pelvis,  and  extension  to  the  lower  Hmbs,  or,  best  of 
all,  the  orthopedic  surgeon's  wire  cuirass  to  immobilize  the  w^hole 
body.  Prolonged  rest  in  bed — six  to  twelve  weeks — is  necessary. 
In  the  case  of  suppuration  of  the  joints,  an  incision  into  them  from 
behind  to  evacuate  the  pus  and  to  allow  of  drainage  is  indicated. 

The  mortality  of  injur}^  to  the  sacro-iliac  joints  in  labor  has 
been  thirty  per  cent. 

Fracture  of  the  Pelvic  Bones. — This  very  rare  accident  in 
labor  has  usually  been  the  result  of  the  unskilful  use  of  forceps. 
It  is  serious  but  not  necessarily  fatal.  In  a  case  reported  by 
Studley,^  of  a  fracture  of  the  horizontal  and  of  the  descending 
ramus  of  the  pubis,  the  woman  recovered.  Bird^  also  reports  a 
recovery  after  a  fracture  of  the  horizontal  ramus  of  the  pubis 
before  the  application  of  forceps,  and  the  author  has  seen  one 
case  with  like  result,  in  which  forceps  was  applied  and  powerful 
traction  was  made. 

Fracture  of  the  sacrococcygeal  joint,  or  of  the  coccyx, 
occurs  ver\'  rarely  in  elderly  primiparae,  in  whom  not  only  the 
sacrococcygeal  joint,  but  the  joints  of  the  coccyx  as  well,  are 
ankylosed.  The  fracture  may  be  caused  spontaneously  by  the 
expulsive  efforts  of  the  mother  driving  the  presenting  part  down 
upon  the  pelvic  floor  ;  but  it  is  more  commonly  the  result  of  the 
application  of  forceps  and  the  forcible  extraction  of  the  head 
through  the  pelvic  outlet.  There  are,  in  my  experience,  four 
t}"pes  of  injury  to  the  coccyx  in  labor.  In  one  there  is  an  oblique 
fracture  of  a  coccygeal  vertebra  involving  a  joint  and  resulting 
in  painful  mobility  of  the  bone.  In  the  second  there  is  ankylosis 
of  the  tAvo  fragments  with  the  lower  one  drawn  in  at  a  right  angle, 
where  it  is  out  of  the  way  and  causes  no  inconvenience  or  discom- 
fort except  in  a  subsequent  labor.  In  the  third  the  lower  frag- 
ment is  ankylosed  in  a  perpendicular  position,  causing  great  pain 
when  the  patient  attempts  to  sit.  In  the  fourth  there  is  a  strain, 
sprain,  or  ^n  actual  rupture  of  a  coccygeal  joint,  with  abnor- 
mal mobility  and  chronic  inflammation  of  the  intervertebral  disc, 
\^dth  consequent  hypertrophy  and  softening.  This  last  form  is 
by  far  the  commonest.  The  injury  often  results  in  the  condition 
known  as  coccygodynia  after  the  completion  of  the  puerperium. 

Diastasis  of  the  Abdominal  Muscles. — Reference  has  been 
made  to  the  escape  of  the  uterus  from  the  abdominal  cavity 
between  the  recti  muscles  in  labor.  After  deliver}'  these  muscles 
stand  widely  apart  and  threaten  the  woman  with  pendulous  belly, 
ptosis  of  the  abdominal  viscera,  and  even  with  abdominal  hernia 
when  she  rises  from  bed.  Diastasis  of  the  recti  muscles  is 
not  uncommon   after   labor.        It   is    usually    observed    without 

1  ''American  Journal  of  Obstetrics,'  April,  1879. 
'  "American  Journal  of  Obstetiics,"  Jan.,  1902. 


LABOR    COMPLICATED  BY  ACCIDENTS  AND  DISEASES.     621 


precedent  actual  hernia  of  the  parturient  uterus.  The  condition 
can  usually  be  corrected  by  a  firm  abdominal  binder  during  puer- 
peral convalescence  or  longer.  If  it  is  not,  and  does  not  yield  to 
abdominal  massage,  electricity,  and  Swedish  exercises,  the  oper- 
ation of  diminishing  the  width  of  the  aponeurosis  proposed  by 
J.  C.  Webster^  may  be  indicated. 

Rupture  of  Some  Part  of  the  Respiratory  Tract  and  Sub= 
cutaneous  Emphysema.— During  the  straining  of  the  second 
stage  of  labor,  the  larynx  or  trachea 
may  be  ruptured.  This  accident  is  fol- 
lowed by  emphysema  of  the  neck  and 
face.  The  accident,  if  confined  to  the 
trachea  or  larynx,  and  resulting  only  in 
emphysema  of  the  face,  is  not  danger- 
ous. If  the  emphysema  is  more  exten- 
sive, however,  or  if  there  is  a  rupture 
of  the  pulmonary  vesicles,  with  emphy- 
sema of  subpleural  and  interlobular 
connective  tissue,  with  embarrassment 
of  heart  and  lungs,  the  prognosis  is  not 
so  good.  As  soon  as  the  nature  of  the 
injury  is  recognized  the  patient  must  be 
forbidden  to  strain,  and  should  be  de- 
livered as  quickly  as  possible  by  forceps 
or  version.- 

Sudden  Death  During  or  Directly 
After  Labor. — The  causes  of  this  acci- 
dent to  the  parturient  woman  are  set 
down,  as  far  as  possible,  in  the  order 
of  their  frequency. 

Shock. — A  few  sudden  deaths  dur- 
ing and  after  labor  may  be  explained  by 
surgical  shock,  which  is  more  Hkely  to 
follow  a  serious  accident,  such  as  rup- 
tured uterus  in  labor,  but  may  result 
from  the  strain  and  suffering  of  parturi- 
tion in  weak,  hyperesthetic  indi\iduals, 
without  any  serious  com])lication. 

Heart=failure  is  usually  due  to  acute  dilatation  in  the  second 
stage  of  labor,  but  may  be  the  result  of  ad\anced  kidney  disease, 
of  fatty  degeneration  of  the  heart  itself,  of  a  fibroid  patch  in  its 
walls,  of  rupture  of  an  aneurysm,  of  myocarditis,  and  of  a  number 
of  other  conditions  that  might  interfere  with  normal  heart-action. 

1  "Journal  of  the  American  Medical  Association,"  Dec.  22,  1900. 
'•^  Scheffelaar  Klots  has  collected  40  cases,  "Ztschr.  f.  Geb.  u.  Gyn.,"  Bd.  xli, 
H.  3. 


Fig.  504. — Median  section 
of  coccyx  imbedded  in  paraffin, 
showing  an  oblique  fracture  run- 
ning through  the  second  verte- 
bra. The  vacant  space  between 
the  lower  end  of  the  anterior 
fragment  and  the  main  body  of 
the  bone  was  filled  with  an  ex- 
uberant mass  of  spongy  bone-, 
tissue  that  dropped  oft"  when  the 
bone  was  taken  out  (author's 
case). 


622 


THE    PATHOLOGY   OF  LABOR. 


Fig.  505. — Coccyx  ruptured  in  second  joint  by  a  forceps  delivery.     Ankylosis  of  all 
the  other  joints  (author's  case). 


Fig.  506.— Coccyx  ruptured  in  first  joint  by  a  fall  on  the  ice  in  eighth  month  of 
pregnancy.      Injury  aggravated  by  labor  (author's  case). 


LABOR    COMPLICATED   BY  ACCIDENTS  AND  DISEASES.    623 

In  women  with  diseased  and  weak  hearts  so  small  a  matter  as  an 
intra-uterine  injection  has  caused  heart-failure. 

Accidents  of  Labor. — Any  of  the  serious  accidents  of  labor  may 
produce  death  by  shock  or  by  hemorrhage,  as  accidental,  unavoid- 
able, or  postpartum  hemorrhage;  rupture  or  inversion  of  the  womb. 

Rupture  of  Hematomata. — A  rupture  of  a  hematoma,  exter- 
nal or  internal,  may  kill  a  patient  by  shock  or  by  hemorrhage. 
In  a  case  under  my  care  a  hematoma  in  the  outermost  part  of 
the  left  broad  ligament,  rupturing  eighteen  hours  after  delivery, 
caused  death  in  a  veiy  short  time  by  internal  bleeding. 

Syncope. — There  is  a  disposition  in  many  women  after  labor  to 
faint,  but  even  complete  syncope  at  this  time  is  rarely  fatal.  If 
it  depends,  however,  upon  hemorrhage,  thromboses  may  form  in 
the  heart,  or  those  in  the  uterine  sinus  may  be  prolonged,  and 
embolism  may  result.  Prolonged  syncope,  associated  with  air- 
hunger  and  other  symptoms  of  profuse  internal  hemorrhage,  is 
almost  always  fatal. 

Embolism  and  Thrombosis  of  the  Pulmonary  Artery. — This 
may  be  the  result  of  syncope,  or  may  be  caused  by  the  detach- 
ment of  an  embolus  from  the  pelvic  blood-vessels.  The 
embolus,  it  is  claimed,  may  be  a  globule  of  air,^  or  may  be  fat 
from  the  pelvic  connective  tissue.  The  symptoms  of  the  acci- 
dent are  :  sudden  shock,  a  rapid-running  pulse,  heart-failure, 
rapid  respiration,  air-hunger,  followed  usually  in  a  few  moments 
by  death  ;  but  the  accident  is  not  invariably  fatal.  I  have  seen 
one  well-marked  case  recover.  The  only  treatment  possible  is 
stimulation,  slight  elevation  of  the  body,  and  lowering  of  the 
head,  with  absolute  quiet. 

Profound  Mental  Impressions. — Profound  emotion  may  cause 
a  woman's  death  during  or  directly  after  labor.  The  following 
case  was  described  to  me  by  a  friend  who  witnessed  it.  A 
widow,  in  good  position,  applied  for  treatment  for  abdominal 
tumor.  She  was  told  that  she  was  pregnant,  but  she  vehemently 
denied  the  possibility  of  her  condition.  A  little  later  her  phy- 
sician was  summoned  to  attend  her  in  what  he  found  to  be  labor. 
He  told  her  again  of  her  condition,  but  she  again  denied  it,  and 
throughout  the  whole  of  her  labor  she  indignantly  protested  that 
it  could  not  be  so.  Finally,  when  the  child  was  delivered,  it  was 
held  up  before  her  as  a  proof  that  her  physician  was  correct. 
She  passed  at  once  into  a  maniacal  condition,  cr\-ing  out  that  the 
child  was  a  tumor,  that  she  had  not  been  pregnant  at  all,  and 
after  a  few  minutes  she  died.  A  careful  postmortem  e.xamination 
revealed  no  physical  cause  for  her  death. 

1  Since  I  saw  my  friend,  Professor  H.  A.  Hare,  inject  whole  syringefuls  of  air 
into  the  jugular  vein  of  a  dog  without  detriment  to  the  animal,  I  confess  to  a  skepti- 
cism in  regard  to  air-embolism  as  a  cause  of  death  in  the  child-bearing  woman. 


624  THE   PATHOLOGY   OF  LABOR. 

Other  causes  of  sudden  death  during  and  after  labor  that  have 
been  reported  are  :  a  brain  tumor,  rupture  of  a  gastric  ulcer, 
acute  purpura  haemorrhagica,  rupture  of  peritoneal  adhesions, 
rupture  of  the  aorta,  rupture  of  a  cyst  in  the  auricular  septum 
of  the  heart,  retro -peritoneal  hemorrhage  from  the  head  of  the 
pancreas,^   and  angina  pectoris. 

Effect  of  Maternal  Death  upon  the  Fetus. — The  fetus  rarely 
survives  its  mother's  death  more  than  a  few  minutes,  and  usually 
the  death  of  mother  and  child  is  synchronous.  An  interesting 
case  was  reported  to  me  by  a  surgeon  on  an  American  man-of- 
war  in  the  harbor  of  Rio  Janeiro  during  the  revolution  in  Brazil. 
A  pregnant  woman,  near  term,  was  struck  by  a  fragment  of  an 
exploding  shell.  She  was  killed  immediately.  She  had  scarcely 
fallen  to  the  ground  when  a  Brazilian  surgeon,  who  was  standing 
near,  cut  open  her  abdomen  and  uterus  with  a  penknife,  but  the 
child  was  extracted  dead.  Tarnier  reports  an  extraordinary  case 
in  which  it  appeared  that  the-  child  lived  for  two  hours  after  its 
mother's  death.  During  the  Commune  in  Paris  the  rioters  fired 
upon  the  Maternity  Hospital.  A  pregnant  woman,  sitting  upon 
her  bed  in  a  ward,  was  shot  through  the  head  and  instantly 
killed.  After  a  while  she  was  discovered  dead,  and  Tarnier  was 
summoned  to  do  postmortem  Cesarean  section,  as  fetal  heart- 
sounds  were  still  heard.  Beginning  the  operation  with  his  assist- 
ants, the  rioters  fired  upon  the  operators,  and  it  was  necessary  to 
remove  the  woman  to  the  cellar  before  the  attempt  could  be 
repeated.  After  an  interval  of  an  hour  and  three-quarters,  or 
more,  the  operation  was  at  length  performed,  and  a  living  child 
extracted  from  the  mother's  womb. 

In  case  of  death  in  a  pregnant  woman  near  term,  the  fetal 
heart-sounds  should  be  listened  for  carefully,  and,  if  they  are 
heard,  an  immediate  attempt  should  be  made  to  extract  the  child. 
This  can  be  done  by  postmortem  Cesarean  section,  or,  better,  I 
think,  by  forced  dilatation  of  the  cervix,  version,  and  rapid  ex- 
traction. I  have  had  one  experience  in  such  a  case,  in  which 
the  dilatation  of  the  cervix  and  the  extraction  of  the  child  pre- 
sented no  difficulties  at  all,  and  were  completed  in  a  very  few 
moments.  If  the  patient  is  seen  in  articulo  mortis,  it  is  unques- 
tionably better  to  deliver  her  by  forcible  dilatation  of  the  cervix 
and  version  rather  than  to  await  her  death  and  then  to  perform 
a  postmortem  Cesarean  section. 

Postmortem  Delivery. — There  is  reported  from  time  to  time 
the  birth  of  a  child  in  its  mother's  coffin,  giving  rise  to  the  horri- 
ble suspicion  that  the  pregnant  woman  had  been  buried  alive, 
and  had  fallen  into  labor  when   she  awoke  from  her  trance  and 

^  Van  de  \'elde,  "  Jahresbericht,"  vol.  xii,  ji.  764. 


LABOR    COMPLICATED   BY  ACCIDENTS  AND   DISEASES.   625 

realized  her  dreadful  position.  These  cases,  however,  may  be 
explained  by  the  accumulation  of  gas  within  the  abdominal  cavity 
due  to  decomposition,  which  so  increases  the  intra-abdominal 
pressure  as  to  drive  the  fetus  out  of  the  woman's  body.  Such 
cases  are  more  common  in  hot  climates,  where  decomposition 
progresses  rapidly.^ 

Accidents  to  the  Fetus. — Prolapse  of  the  Cord. — The  cord  is 
said  to  be  prolapsed  when  it  presents  with  or  shps  beyond  the 
presenting  part. 

Frequency. — According  to  Winckel,  the  frequency  of  prolapse 
of  the  funis  varies  in  different  clinics  from  i  :  65  to  i  :  500. 
Churchill  found  it  once  in  245  labors;  Christisen,  once  in  65  ; 
Meachem,  once  in  93  ;   Bland,  once  in  1897  labors. 

Causes. — The  causes  of  prolapse  of  the  cord  are,  in  the  first 
place,  a  lack  of  conformity  of  the  presenting  part  with  the  shape 
and  size  of  the  pelvic  inlet,  as  in  a  flat  pelvis  or  a  compound  pre- 
sentation, and  with  this  condition  an  exaggerated  length  of  the 
cord,  placenta  praevia,   marginal  insertion,    hydramnios^   sudden 


Fig.   507. — Trendelenburg  posture  over  a  chair  to  guard  a  prolapsed  cord  from  pres- 
sure and  to  facilitate  its  reposition  (Dickinson). 

rupture  of  the  membranes  and  violent  expulsion  of  the  liquor 
amnii ;  delivery  in  the  semirecumbent,  sitting,  or  erect  posture, 
and  violent  jolts  or  jars  such  as  a  parturient  patient  would  ex- 
perience during  transportation  to  a  hospital  in  an  ambulance. 

1  Stumpf  claims  that  postmortem  deliveries  may  be  due  to  a  rigor  mortis  of  the 
uterine  muscles,  "  Monalschr.  f.  Geb.  u.  Gyn.,"  Bd.  viii,  p.  64. 
40 


626 


THE   PATHOLOGY  OF  LABOR. 


The  diagnosis  should  present  no  difficuky.  There  is  nothing 
else  in  the  cervical  canal  or  vagina,  during  labor,  which  feels  like 
the  cord  or  should  be  mistaken  for  it.  It  is  sometimes  actually- 
visible  at  the  vulvar  orifice,  and  may,  in  case  of  doubt,  be  pulled 
out  and  inspected.  If  the  child  is  alive,  the  pulsating  vessels  in 
the  cord  may  be  felt.  I  was  once  called  in  consultation,  how- 
ever, by  a  young  physician  who  believed  that  a  coil  of  intestine 
had  prolapsed  into  the  vagina. 

The  prognosis  for  the  child  is  grave.  The  mortality  in  gen- 
eral is  more  than  fifty  per  cent.  The  child  obviously  dies  of 
asphyxia  from  pressure  upon  the  cord;  hence 
the  danger  is  twice  as  great  in  head  presenta- 
tions (sixty-four  per  cent.)  as  in  breech  presenta- 
tions (thirty-two  per  cent.).  The  danger  to  the 
mother  lies  in  the  operative  procedures  which 
are  often  required  for  the  reposition  of  the  cord, 
such  as  version  and  rapid  extraction. 

Treatment. — The  cord  should  be  replaced  by 
manipulation  with  the  woman  in  a  knee-chest 
posture,  or,  better,  the  Trendelenburg  posture — 
over  the  back  of  a  chair.  It  is  advisable  to 
hook  a  loop  of  the  cord  over  an  extremity  or 
the  chin  to  prevent  its  prolapsing  again,  which 
is  extremely  Hkely.  The  whole  hand  must 
be  inserted  in  the  vagina,  and  perhaps  within 
the  lower  uterine  segment;  so  that  anesthesia 
is  usually  required.  While  the  anesthetic  is 
administered,  and  while  the  physician  makes  his 
preparations  for  the  reposition,  the  patient  should  be  kept  in  the 
Trendelenburg  posture,  so  as  to  guard  the  cord  from  fatal  pres- 
sure. If  the  cord  is  satisfactorily  replaced  so  that  it  will  not 
come  down  again,  forceps  should  be  applied  to  the  head  to  fix  it 
firmly  over  the  pelvic  inlet.  If  the  os  is  not  sufficiently  dilated 
to  allow  the  application  of  forceps,  a  dilatable  rubber  bag  (Barnes', 
Braun's,  or  Voorhees')  should  be  inserted  in  the  cervix  or  in  the 
lower  uterine  segment  and  distended  with  water  to  prevent  pro- 
lapse of  the  cord  while  the  cervical  canal  is  undergoing  efface- 
ment  and  dilatation.  If  manipulation  fails  to  replace  the  cord, 
podalic  version  should  be  performed  without  waste  of  time.  The 
breech  being  firmly  impacted  in  the  pelvis,  the  case  is  managed 
as  one  of  breech  presentation — by  delay  until  the  os  is  well 
dilated  and  the  cervix  paralyzed,  and  then  by  rapid  extraction. 
If  the  head  is  presenting  and  is  engaged  so  that  version  is  out 
of  the  question,  the  cord  should  be  so  disposed  as  to  be  least 
pressed  upon  (for  example,  opposite  the  left  sacro-iliac  junction 
in  a  left  occipito-anterior  position  of  a  vertex  presentation)   and 


Fig.  508. — Impro- 
vised repositor. 


DYSTOCIA   DUE    TO   DISEASE.  62/ 

the  head  rapidly  extracted  with  forceps.  In  prolapse  of  the  cord 
with  a  breech  presentation,  the  cord  should  be  replaced  by  manip- 
ulation in  the  Trendelenburg  posture;  a  foot  should  be  seized  and 
brought  down  until  the  breech  is  firmly  impacted  in  the  pelvis. 

The  instrumental  reposition  of  the  cord  is  usually  unsatis- 
factory and  unnecessary.  Manipulation  accomplishes  more  than 
can  be  done  by  a  repositor.  Occasionally,  however,  it  might  be 
convenient  to  remember  the  device  illustrated  in  figure  508.  A 
loop  of  string  or  tape  is  tied  double  around  the  end  of  a  stiff 
catheter  or  bougie.  The  free  loop  is  caught  over  the  cord  and 
the  end  of  the  instrument  which  is  carried  high  up  into  the 
uterine  cavity.  Should  it  be  desirable  to  withdraw  the  instru- 
ment, it  can  be  done  without  pulling  the  cord  out  with  it. 

Rupture  of  the  Cord. — It  has  been  shown  by  experiments  that 
the  healthy  umbilical  cord  can  stand  a  strain  of  8^  pounds 
on  the  average,  the  weakest  5  ^  pounds,  and  the  strongest 
15  pounds.  It  is  obvious,  therefore,  that  the  weight  of  an 
ordinary  fetus  may  be  enough  to  rupture  the  cord,  and  it  is 
almost  certain  to  do  so  if  the  weight  is  increased  by  a  drop  or 
violent  expulsion,  and  if  the  placenta  remains  attached.  Hence, 
precipitate  delivery  in  the  erect  posture  is  often  accompanied  by 
rupture  of  the  cord  usually  at  the  umbilicus,  although  in  one  of 
my  cases  it  tore  off  at  the  placental  insertion.  Spaeth  and 
Budin  have  each  reported  a  case  of  rupture  of  the  cord  while 
the  woman  was  recumbent,  and  the  latter  has  also  reported  a 
case  in  which  the  weight  of  the  placenta,  suddenly  expelled  and 
dropping  the  full  length  of  the  cord,  snapped  the  latter  in  two. 
A  ruptured  cord  usually  does  not  bleed.  If  it  is  torn  off  at  the 
umbilicus  and  the  vessels  bleed,  they  should  be  pulled  out  by  a 
tenaculum  and  ligated,  or,  if  this  is  impracticable,  hare-lip  pins 
should  be  inserted  under  the  umbilicus  and  a  figure-of-eight  liga- 
ture applied. 

The  treatment  of  rupture  of  the  umbilical  cord  is  pre- 
ventive. Labor  in  the  erect  posture  should,  of  course,  never 
be  allowed,  and  a  precipitate  labor  must  be  retarded  ;  violent 
traction  upon  a  coiled  cord  has  ruptured  it.  It  is  better,  in  such 
cases,  to  cut  the  cord  between  ligatures  and  to  extract  the  child 
quickly. 

DYSTOCIA  DUE  TO  DISEASE. 

Convulsions. — ConvuLsions  in  the  child-bearing  woman  may 
be  defined  as  muscular  spasms,  with  or  without  unconsciousness, 
occurring  during  pregnancy,  parturition,  or  the  puerperium. 

Causes. — The  convulsions  may  be  due  to  eclampsia,  hysteria, 
epilepsy,  tumors  of  the  brain,  cysticercus,^  and  meningitis  ;  to  the 

1  Pestalozza,  "  Rivist.  Critic,  di  Clinic.  Medic,"  1900. 


628  THE   PATHOLOGY  OF  LABOR. 

profound  anemia  following  postpartum  and  other  hemorrhages, 
and  to  apoplexy  ;  or  there  may  be  an  exaggeration  of  the  nerv- 
ous irritability  characteristic  of  the  child-bearing  period,  in  con- 
sequence of  which  convulsions  may  arise  from  some  trifling  irri- 
tation, as  that  of  an  overdistended  bladder,  overloaded  bowels, 
the  introduction  of  the  hand  in  performing  version,  the  pressure 
of  the  head  upon  the  perineum,  and  excessive  after-pains.  Puer- 
peral convulsions,  therefore,  is  a  symptom  indicative  of  a  variety 
of  pathological  conditions. 

Eclampsia  is  a  name  given  to  the  most  frequent  variety  of 
convulsions  in  the  child-bearing  woman,  the  result  of  kidney 
insufficiency  and  of  a  gestational  toxemia.  It  is  derived  from  a 
Greek  word  signifying  to  shine  or  flash  out,  and  was  conferred 
upon  the  condition  on  account  of  its  sudden  onset.^ 

Causes. — Since  Lever's^  discovery  of  the  albuminuria  usually 
preceding  and  accompanying  eclampsia,  kidney  insufficiency  has 
been  regarded  as  the  chief  cause  of  eclampsia,  but  recent  studies 
in  the  toxemia  of  pregnancy,  while  not  diminishing  the  importance 
of  imperfect  elimination  by  the  kidneys  in  the  etiology  of  eclampsia, 
have  established  other  factors  in  the  causation  of  the  disease.  The 
several  theories  advocated  at  present  start  with  the  common  assump- 
tion that  the  ovum  or  fetus  is  the  source  of  toxins  contaminating 
the  maternal  blood.  What  these  toxins  are  and  where  they  origi- 
nate is  still  unknown.  Kollmann^  points  out  that  the  fibrin-form-  _ 
ing  elements  of  the  blood  are  much  increased  in  eclampsia.  To 
these  globulins,  albuminous,  large  molecular  bodies  which  furnish 
the  excess  of  fibrin,  is  ascribed  the  toxicity  of  the  maternal  blood. 
There  is  much  to  support  this  view.  Experimentally  these  sub- 
stances have  been  demonstrated  to  be  toxic,  producing  eclamptic 
symptoms.  The  negative  results  of  cryoscopy  in  the  urine  of 
eclamptic  patients  indicate  that  there  is  an  excretion  of  high  atomic 
large  molecular  substances.  Whether  these  substances,  if  they 
are  the  toxins  of  eclampsia,  are  derived  from  fetal  metabolism  or 
from  the  syncytium  of  the  placenta  is  disputed.  The  author 
favors  the  former  view  for  the  following  reasons :  The  toxemia  of 
early  pregnancy,  which  is  probably  due  to  the  syncytial  growth, 
differs  in  its  clinical  manifestations  from  the  toxemia  of  the  latter 
half  of  pregnancy;  eliminative  treatment  and  dietetic  management 
to  spare  the  kidneys  and  liver  favorably  influence  the  toxemia  of 
the  second  half  of  pregnancy,  but  have  no  effect  on  the  toxemia  of 
the  first  half.     The  symptoms  of  the  toxemia  of  the  latter  half  of 

*  Hippocrates  used  the  word  e^^af-HJJC^  to  designate  a  sudden  rise  of  temperature. 
In  the  middle  of  the  eighteenth  century  Boissier  de  Sauvages  mistakenly  applied 
the  word  to  convulsions.  The  correct  term  would  be  eclactisma  {ex^ayrct^^ecv,  "to 
kick  backward"). 

^  "Guy's  Hospital  Reports,"  1843.  ^  "  Centralbl.  f.  Gyn.,"  1897,  No.  13. 


DYSTOCIA   DUE    TO  DISEASE.  629 

pregnancy  usually  disappear  with  the  death  of  the  fetus;  in  mul- 
tiple pregnancies  albuminuria  and  eclampsia  are  ten  times  more 
frequent  than  in  single  pregnancies;  in  hydatidiform  mole  with 
its  enormous  overgrowth  of  syncytium  eclampsia  is  rare;  only  two 
cases  are  recorded. 

The  toxins  in  the  maternal  blood  are  conveyed  first  to  the  liver, 
where  they  are  converted  into  substances  fit  for  elimination  by  the 
kidneys.  If  the  liver  fails  in  its  functions  or  breaks  down  under  the 
strain  imposed  upon  it,  the  maternal  blood  contains  toxic  material 
irritating  to  the  kidneys,  the  central  nervous  system,  and  the  capil- 
laries everywhere.  The  kidneys  manifest  the  irritation  of  their  capil- 
laries and  of  their  epithelium  by  the  symptoms  of  parenchymatous 
nephritis.  Clinically  it  appears  that  even  if  the  hepatic  function 
is  imperfectly  performed  functionally  active  kidneys  are  competent 
to  excrete  the  imperfectly  oxidized  excrementitious  matters  in  the 
maternal  blood.  On  the  contrary,  with  impaired  excretory  power 
in  the  kidneys,  a  cumulative  toxemia  develops,  ending  in  eclampsia. 
The  following  facts  support  this  view:  Hepatic  degeneration,  in 
some  cases  to  the  grade  of  acute  yellow  atrophy,  is  a  constant  con- 
dition in  post-mortem  examinations  of  eclamptic  patients;  a  small 
proportion  of  cases  display  no  kidney  insufficiency  prior  to  the 
eclampsia  (10  to  16  per  cent.).  But  some  form  of  kidney  disease  is 
discovered  post-mortem  in  the  large  majority  of  cases:  In  18  out 
of  81  autopsies  Herzfeld  found  the  ureters  compressed  at  the  pelvic 
brim  and  dilated;  in  more  than  four-fifths  of  the  cases  eclampsia 
is  preceded  by  albuminuria  and  other  signs  of  kidney  breakdown; 
as  the  kidney  symptoms  increase  in  severity  eclampsia  becomes 
more  imminent;  with  improvement  in  the  kidney  symptoms  the 
danger  of  eclampsia  decreases;  examinations  of  the  urine  show 
apparently  an  imperfect  oxidization  of  the  nitrogenous  bodies  ex- 
creted.^ 

Nicholson^  has  advanced  the  theory  that  the  thyroid  gland  is 
the  most  important  factor  in  furnishing  an  antibody  for  the  toxins 
of  pregnancy.  Adequate  hypertrophy  and  hypersecretion  of  the 
gland,  which  is  the  rule  in  pregnancy,  safeguards  a  pregnant 
woman  against  toxemia;   inadequate  activity  predisposes  her  to  it. 

In  spite  of  the  enormous  amount  of  investigation  to  which  this 
subject  has  been  subjected  in  the  last  decade  it  is  not  yet  possible 
to  explain  the  etiology  of  eclampsia  fully.  The  only  facts  on 
which  there  is  agreement  at  present  are  that  there  is  a  toxin  or  toxins 
in  the  blood  of  the  pregnant  woman  derived   from  the  ()^•um  or 

1  Massen,  Ludwig,  Savor,  Wliitney,  Clapp;  "  Centralbl.  f.  Gyn.,"  1S95,  No. 
42;    "Am.  Gyn.,"  August,  1903. 

-  "Jour,  of  Obstet.  and  Gyn.  of  the  Br.  Empire,"  July,  1902;  "Brit.  Med. 
Journ.,"  Oct.  3,  1903. 


630  THE   PATHOLOGY  OF  LABOR. 

fetus;  that  these  substances  affect  mainly  the  liver  and  kidneys; 
that  a  breakdown  of  either  of  these  organs  results  in  a  toxemia; 
that  the  accumulated  toxins  probably  are  intensely  irritating  to 
the  capillaries;  that  either  in  consequence  of  an  acute  anemia  of 
the  brain,  due  to  contraction  of  the  capillaries  or  to  a  direct  irrita- 
tion of  the  central  nervous  system,  convulsions  appear. 

From  the  clinical  point  of  view  it  is  a  mistake  to  minimize  the 
importance  of  the  kidneys.  The  examination  of  the  urine  gives 
us  the  first  premonitory  signs  of  gestational  toxemia  in  the  latter 
half  of  pregnancy  in  more  than  four- fifths  of  the  cases,  and  a  treat- 
ment to  avoid  strain  on  the  kidneys  and  to  promote  free  urinary 
excretion  is  the  only  effective  preventive  treatment  of  eclampsia 
except  the  termination  of  pregnancy. , 

There  must  be  taken  into  account  also  the  extreme  irritability 
of  the  child-bearing  period,  predisposing  to  convulsive  outbreaks.^ 
Five  per  cent,  of  eclamptic  cases  are  reflex  and  not  toxemic  (Duhrs- 
sen). 

The  kidneys  in  pregnancy  may  become  insufficient  for  the 
work  of  disposing  of  excrementitious  matters  from  both  maternal 
and  fetal  bodies,  by  reason  of  the  kidney  of  pregnancy,  of  ne- 
phritis, of  increased  intra-abdominal  pressure,  or  of  direct  pres- 
sure upon  the  ureters.  It  is  important  in  practice  to  appreciate 
that  the  kidneys  may  be  diseased  and  yet  functionally  sufficient, 
or  that  they  may  be  healthy  anatomically,  but  functionally  insuf- 
ficient for  their  double  work. 

Frequency. — Eclampsia  occurs  about  once  in  300  cases  of 
pregnancy.  It  is  most  frequently  seen  in  primiparae,  and  more 
frequently  in  women  illegitimately  pregnant.  It  most  often 
occurs  during  labor,  is  next  in  frequency  during  pregnancy,  and 
occurs  least  frequently  during  the  puerperium.  It  is  ten  times  as 
frequent  in  multiple  pregnancies  as  in  single  pregnancies,  and 
occurs  with  greater  frequency  in  climatic  conditions  which  inter- 
fere with  the  free  activity  of  the  skin  and  throw  extra  work  upon 
the  kidneys. 

Symptoms. — Eclampsia  should  always  be  feared  if  there  are 
signs  of  kidney  disease  or  disturbance  during  pregnancy,  for 
diseased  kidneys  are  more  likely  to  be  insufficient  than  healthy 
kidneys,^  and  in  more  than  four-fifths  of  the  cases  gestational  tox- 
emia is  first  manifested  by  marked  and  increasing  albuminuria. 
Increasing  blood  pressure  is  the  most  constant  symptom  of  gesta- 
tional toxemia  in  the  latter  half  of  pregnancy,  and  is  an  invariable 
precursor  of  eclampsia.  The  other  symptoms  of  toxemia  should 
also    serve   as   danger    signals;    namely,    digestive   disturbances, 

1  Meyer- Wirz,  "  Klinische  Studie  ueber  Eklampsie,"  "Arch.  f.  Gyn.,"  Bd.  Ixxi, 
H.  I. 


DYSTOCIA    DUE    TO  DISEASE. 


631 


rapidity  of  pulse,  anomalies  of  vision,  oedema,  and  headache. 
The  prodromal  symptoms  of  the  attack  itself  are :  Sharp  pains  in 
the  head,  epigastrium,  or  under  the  clavicle;  muscai  volitantes,  with 
failure  of  vision,  great  restlessness,  or  stupor.  A  few  moments  after 
the  appearance  of  the  prodromal  symptoms  the  attack  comes  on 
with  a  stare;  the  pupils  are  at  first  contracted;  the  eyelids  twitch, 
the  eyeballs  roll,  the  mouth  is  pulled  to  one  side,  the  neck  is  then 
affected,  and  the  head  is  pulled  first  toward  one  shoulder  and 
then  toward  the  other.  The  spasm  finally  spreads  to  the  trunk 
and  upper  extremities;  the  arms  are  strongly  flexed,  the  fingers  are 


Fig.  509. — Stanton's  apparatus  for  measuring  blood  pressure. 


bent  over  the  thumb,  and  the  upper  extremities  work  spasmod- 
ically to  and  from  the  median  line  in  front  of  the  chest.  The 
spasm  of  the  respiratory  muscles  with  the  closure  of  the  teeth  and 
lips  give  rise  to  a  jerky  sort  of  breathing  with  a  characteristic  suck- 
ing sound.  The  lower  extremities  are  rarely  affected,  although 
the  thighs  may  be  flexed  tonically  upon  the  abdomen.  Conscious- 
ness is  lost  during  the  convulsive  attack  and  for  some  time  after- 
w^ard;  with  each  returning  fit  the  stupor  deepens,  until  at  length 
there  is  unbroken  coma.  The  convulsion  lasts  for  a  minute  or 
two.  The  temperature  usually  rises  higher  with  each  convulsion. 
The  patient  often  has  no  recollection  whatever  of  events  during, 
preceding,  and  following  the  whole  period  of  her  convulsive  attacks, 


632  THE  PATHOLOGY  OF  LABOR. 

though  she  may  have  seemed  to  be  perfectly  conscious  the  greater 
part  of  the  time. 

The  urine  is  almost  always  albuminous  after  the  first  or  second 
convulsion;  albuminuria  precedes  the  convulsions  in  more  than 
four-fifths  of  the  cases.  The  percentage  of  urea  and  of  most  of 
the  urine  salts  except  the  chlorids  is  not  necessarily  lowered, 
though  the  total  excretion  is  diminished  owing  to  a  scanty  secretion 
of  urine  sometimes  to  a  complete  anuria.  The  urine  may  con- 
tain methemoglobin  and  oxyhemoglobin  as  well  as  free  blood, 
numerous  casts,  and  desquamated  cells. 

Pathology. — The  lesions  of  eclampsia  are  by  no  means  confined 
to  the  kidney,  in  which,  however,  extensive  degeneration  of  the 
epithelium  or  interstitial  nephritis  is  almost  invariably  found.  In 
18  out  of  81  autopsies  Herzfeld  found  the  ureters  much  dilated  by 
compression  at  the  pelvic  brim.^  In  the  hver,  kidney,  brain,  and 
lungs  are  numerous  thromboses  of  the  small  capillaries,  extrava- 
sations, and  necrotic  areas.  Emboli  of  liver  cells  are  found  in 
the  important  organs.  There  is  degeneration  of  the  myocardium. 
In  the  lungs  there  may  be  edema  or  pneumonia  and  infection 
from  the  inspiration  of  foreign  material  from  the  mouth.  There 
are  also  in  the  lungs  emboli  of  giant  polynuclear  cells  which 
Schmorl  attributes  to  the  surface  of  the  placental  villi,  having, 
indeed,  demonstrated  their  exfoliation,  absorption  into  the  circu- 
lation from  the  intervillous  blood  spaces,  and  their  passage 
through  the  heart  to  the  lungs,  where  they  are  arrested  because 
they  are  too  large  to  pass  the  capillaries.^  Schmorl  attributes 
eclampsia  to  the  exfoliation  of  these  giant  cells.^ 

The  assertion  that  only  5  per  cent,  of  women  with  diseased  kid- 
neys  develop  eclampsia  is  not  strictly  true;  even  if  it  were,  the  pro- 
portion of  one  in  twenty  contrasted  with  one  in  three  hundred 
shows  the  influence  of  imperfect  kidney  action  in  the  etiology  of 
gestational  toxemia  and  eclampsia.  As  a  matter  of  fact,  only  a 
minority  of  patients  with  diseased  kidneys  go  through  pregnancy 
without  some  of  the  manifestations  of  toxemia. 

Differential  Diagnosis. — The  convulsions  of  eclampsia  must 
be  distinguished  from  those  of  epilepsy,  hysteria,  brain  disease, 
hemorrhage,  or  of  some  source  of  irritation  within  the  body,  as 
mentioned  above.  The  distinction  should  be  made  without  diffi- 
culty by  an  examination  of  the  urine.  If  the  patient  is  catheter- 
ized,  and  the  urine  is  heated  in  a  spoon  over  a  gas-lamp  flame, 
it  will  turn   almost  solid  by  the  coagulation   of  albumin   in  it. 

1  "  Centralbl.  f.  Gyn.,"  No.  40,  1901. 

2  Pels  Lensden  has  found  these  giant  cells  in  the  lungs  of  non-eclamptic  patients, 
"  Ztsch.  f.  Geb.  u.  Gyn.,"  xxxvi,  S.  I. 

3  "  Pathologisch-Anatomische  Untersuchungen  iiber  Puerperal -Eklampsie," 
Leipzig,  1893. 


DYSTOCIA    DUE    TO  DISEASE.  633 

About  sixteen  per  cent,  of  the  cases  of  true  eclampsia  show  no 
albuminuria  before  the  convulsions  appear,  but  in  every  case, 
after  the  second  convulsion  at  least,  the  urine  contains  albumen, 
almost  always  in  large  quantities.  Casts  are  present  in  abundance. 
The  other  conditions  causing  convulsions  in  the  child-bearing 
woman  have  their  distinctive  signs  that  serve  to  make  the  differen- 
tial diagnosis  easy. 

Prognosis. — In  general  practice  it  may  be  stated  that  the  mor- 
tality of  eclampsia  is  thirty  per  cent,  but  in  different  localities, 
and  at  different  times,  the  mortality  varies  widely.  For  example, 
the  mortality  in  nine  lying-in  hospitals  in  this  country  during  a 
period  of  five  years  was  38.4  per  cent,  in  78  cases.  The  mor- 
tality of  the  Royal  Maternity  in  Edinburgh  has  been  66.6  per 
cent.  That  of  Guy's  Charity,  in  London,  averages  25  per  cent. 
In  209  cases  in  the  Maternite,  in  Paris,  from  1850  to  1856,  the 
mortality  was  33  per  cent.  Winckel  reports  92  cases,  with  7 
deaths — a  mortality  of  7.6  per  cent.  Veit  reports  more  than  60 
cases,  with  2  deaths — a  mortality  of  3.3  per  cent.  In  46  cases  in 
the  Charite,  in  Berlin,  there  were  6  deaths,  2  of  these  being  due 
to  complications,  so  that  the  mortality  of  the  eclamptic  cases  was 
8.5  per  cent.  It  is  claimed  that  in  Germany  in  general  the  mor- 
tality has  been  reduced  to  between  7  and  10  per  cent.,  but  in  80 
cases  in  the  University  Maternity  of  Berlin,  the  death-rate  was 
21.25  P^^  cent.  In  the  Maternity  Hospital  of  Christiana  there 
were  160  cases  from  1895-1904,  with  a  mortality  of  26  per  cent. 
In  496  cases  in  Olshausen's  clinic  the  mortahty  was  2 1.4  per  cent.^ 
In  the  Maternity  of  the  University  of  Pennsylvania  the  mortality 
in  128  cases  was  -^-^  per  cent.,  but,  excluding  the  cases  admitted  in 
such  bad  condition  that  death  ensued  in  less  than  twelve  hours, 
the  mortality  is  less  than  13  per  cent. 

The  causes  of  death  may  be  edema  of  the  brain,  of  the  lungs, 
or  of  the  larynx;  apoplexy,  asphyxia,  exhaustion,  heart-failure; 
thrombosis  and  embolism  in  important  vessels,  especially  the  pul- 
monary arteries,  insufflation  of  foreign  substances  (food,  blood) 
into  the  lungs,  and  bronchopneumonia,  or  an  overwhelming  accu- 
mulation of  the  poison  of  eclampsia  in  the  system.  In  one  of  my 
patients  there  was  gangrene  of  the  lungs  and  in  another  purpura 
hemorrhagica  of  the  most  malignant  type.  The  mortality  is 
greatest  during  pregnancy  and  least  in  the  pucr])crium.  The 
greater  the  number  of  convulsions  and  the  shorter  the  interval 
between  them,  the  graver  the  outlook;  but  death  may  follow  the 
first  convulsion  and  recovery  has  been  observed  after  sixty-nine.^ 

1  "Ztschr.  f.  Geb.  u.  Gyn.,"  Bd.  Iviii. 

''■  Lithgow,  "Br.  Med.  Journ.,"  JMarcli  26,  1904. 


634  THE   PATHOLOGY  OF  LABOR. 

Rapid  pulse  and  high  temperature  are  unfavorable  symptoms. 
Nothing  is  so  uncertain  as  the  result  of  eclampsia.  The  physician 
should  never  relinquish  hope  of  recovery  until  death  actually 
occurs,  but  should  not  be  too  confident  even  in  apparently  favor- 
able cases. 

The  mortality  of  the  child,  if  eclampsia  occurs  during  preg- 
nancy or  labor,  is  about  50  per  cent.^ 

The  following  detailed  statistics  of  112  cases  are  taken  from 
the  records  of  the  University  Maternity  : 

Patients,  112.      Ages,  fifteen  to  forty-two. 

Primiparse,  84. 

Multiparse,  28  ;  of  whom  four  had  two  children  ;   one,  3  ;   three,  4  ;   one,  5  ;  two,  6  ; 

three,  8  ;   and  one,  10.      The  one  with  8  had  had  eclampsia  in  last  six  preg- 
nancies.     The  women  with  3,  5,  and  6  had  had  one  attack  before. 
Multiple  pregnancies  ^  3 ;  all  twins  and  two  mothers  died. 
Premature  cases,  29  ;  one  at  4^,  one  at  5,  two  at  6^,  nine  at  7,  two  at  7^,  and 

four  at  8  months. 
Cases  at  term,  83. 

Convulsions  varied  from  I  to  199  in  number. 
Urine. — Anuria  in  3  cases.      5'^ij  in  four  days  in  one   case.     Albumin  from  -jJ^-  to 

solid.      Urea  from  0.00 1  to  0.055  percent.       Albumin,  trace  till  first  convul- 
sion and  then  solid,  10  cases.      In  one  case  convulsions  appeared  twelve  hours 

after  delivery ;   in  another,  four  days  after  delivery. 
Time  of  Convulsions  : 

Before  delivery  only  =  41,  of  which  10  died. 

After         "  "      =  14,  of  which  8  died. 

Before  and  after  delivery  =;   15;  of  which  5  died. 
Complications: 

JI/a«/a,  4  cases  (3  multiparae,  5,  4,  8):     I  permanent ;    I  lasted  eight  days  ;    I, 
four  days  ;    I,  seven  days. 

Blind,  3  cases. 

Gangrene  of  lung.  I ;   died. 

One  woman  was  comatose  seventy-eight  hours,  yet  recovered. 

He??iiplegia,  I  case  ;   died. 

Purpura  hemorrhagica,  I  ;   died. 

Hyperpyrexia,  107°,  108°,  1 10°,  3  cases.      Low  temp.,  94°,  i  case. 

Albuminui'ic  retinitis,  5  cases.     Albuminuria  persisted  in  5  cases  ;  cleared  up 
in  42  cases. 
Deaths,  29.     Twelve  hours  or  less  after  admission,  12  ;  more  than  12  hours,  11  ;  died 
undelivered,  4  ;  died  from  ether  nephritis  after  recovery  from  eclampsia,  i.- 

Deaths  in  Primiparse  =  24  =  28.5  %  \  jj-cludino-  all  cases 

Deaths  in  Multiparee  =    5  =-  18      %   |  •"^^^^•"g  ^^^  '^^^^s- 

Total  death-rate,  25  fc  ;  excluding  cases  brought  in  by  the  ambulance  in  a 
hopeless  condition,  13  ^. 
Child.     Thirty-five  children  still-bom,  including  all  premature  cases.      Excluding  15 

cases  under  eight  months  ^  20  dead,  37  alive  (2  twins),  26.3  Jo  ■ 
Operations.     Simple  induction  of  labor  with  spontcneous  delivery,  14  cases  ;  2  deaths. 
A  ccouchement  force. 

Version,  9     ^4  deaths. 

Forceps,  4. 

Craniotomy,  2     ^=  one  death  from  ether  nephritis  after  apparent  recovery. 

Bossi  dilator  and  forceps,  4  =  2  deaths. 
'*  "  "  version,  1  =  1  death. 

1  Enormous  statistics  of  eclampsia  in  "  Jour.  Am.  Med.  Assoc,"  Jan.  2,  1904, 
p.  67.  Also  Goedecke,  "  Zeitschr.  f.  Geb.  u.  Gyn.,"  Bd.  xlv,  S.  5°  i  Glockner, 
"Arch.  f.  Gyn.,"  Bd.  xxxvi,  S.  171 ;  Meyer- Wirz,  "Arch.  f.  Gyn.,"  Bd.  Ixxi,  H.  i 


DYSTO CIA  DUE  TO  DISEA SE.  635 

Venesection,  3  cases  ;  all  died. 
Albuminuria,      {jji  patients. ) 

Quantity,  decided  trace  to  yi  by  bulk  in  boiling. 

Urea  =  o.ooi  to  o  057. 

Labor  induced  to  avert  eclampsia,  II  ;  none  developed  convulsions. 

Convulsions,  II  ;  2  died. 

Multiple  pregnancies  :    twins  once. 

Casts  present,  26  ;  mostly  hyaline  and  granular. 

Marked  edema,  7 ;   two  of  these  women  developed  eclampsia. 

Persistent  vomiting,  7  ;   all  induced  labor.      See  above. 

Patients  who  had  had  eclampsia  before  but  escaped  under  treatment,  40. 

Treatment. — The  preventive  treatment  of  eclampsia  has  been 
in  part  referred  to  in  the  section  upon  the  Management  of  Preg- 
nancy, and  under  the  head  of  Gestational  Toxemia  and  of  Kidney 
Diseases  during  Pregnancy.  As  already  stated,  routine  examina- 
tions of  the  urine  should  be  made  every  two  weeks  until  the  last 
month,  and  then  weekly.  If  any  abnormality  is  found  or  reported, 
such  as  a  very  high  or  low  specific  gravity,  diminution  in  total  quan- 
tity in  the  twenty-four  hours,  albumin  or  casts,  or  if  the  patient 
reports  headache,  disturbance  of  vision,  edema,  gastralgia,  nausea, 
dyspepsia,  palpitation  of  the  heart,  or  a  feeling  of  general  malaise; 
if  she  presents  an  abnormal  appearance,  has  a  rapid  pulse,  coated 
tongue,  foul  breath,  or  a  dry,  harsh  skin,  with  a  sallow  complexion, 
the  total  quantity  of  urine  passed  in  the  twenty-four  hours  should  be 
collected  daily  and  examined  for  albumin,  urea,  specific  gravity, 
and  casts.  Whether  the  urinary  examination  is  satisfactory  or 
not,  the  patient  presenting  symptoms  of  a  gestational  toxemia 
should  be  put  on  a  diet  mainly  of  milk;  meat,  eggs,  fish,  and 
the  stronger  nitrogenous  vegetables  being  excluded.  A  laxative 
at  bedtime,  copious  draughts  of  water,  and  a  diuretic  should  be 
prescribed. 

The  most  valuable  indication  of  the  kidney  condition  is  the 
presence  or  absence  of  albumin  in  the  filtered  urine.  It  is  true  that 
a  small  proportion  of  cases  (less  than  a  fifth)  develop  eclampsia 
without  previous  albuminuria,  but  in  more  than  80  per  cent,  albu- 
min appears  in  the  urine  in  the  early  stages  of  a  gestational  toxemia 
and  gives  timely  warning  of  a  threatened  breakdown  of  the  excre- 
tory organs  and  of  an  outbreak  of  eclampsia.  Much  importance 
was  at  one  time  attached  to  the  excretion  of  urea.  Normally,  a 
pregnant  woman  should  excrete  20  to  24  grams  a  day,  or  about  2 
per  cent.  Careful  examinations,  however,  of  a  number  of  women 
in  the  University  Maternity,  by  Edsall,  with  control  of  the  diet, 
showed  such  irregularity  in  urea  excretion  that  its  estimate  gives  the 
clinician  little  information  of  value.  In  the  routine  examinations 
in  the  hospital  the  urea  elimination  varies  from  3  to  36  grams  a  day 
in  women  on  the  same  diet,  under  the  same  conditions  and  equally 
well.     If,  however,  there  is  persistently  less  than  one  per  cent,  of 


636  THE  PA  THOL  OGY  OF  LAB  OR. 

urea  in  the  urine,  and  less  than  1200  c.c.  a  day  is  passed,  especially 
if ,  at  the  same  time,  there  is  disturbed  digestion  and  coated  tongue, 
the  case  should  at  least  be  regarded  with  suspicion  and  precaution- 
ary dietetic  and  medicinal  treatment  should  be  ordered. 

The  best  test  for  albumin  is  Purdey's,  with  acetic  acid,  ferrocyan- 
ide  of  potassium,  and  the  centrifuge.  The  most  convenient  appa- 
ratus for  estimating  urea  is  Doremus'.  If,  in  spite  of  milk  diet, 
confinement  to  bed,  purgation,  diuresis,  and  diaphoresis,  the  albu- 
min increases  and  the  urea  decreases,  labor  should  be  induced.  It 
must  be  remembered,  however,  that  the  urea  percentage  is  always 
below  normal,  and  sometimes  very  low,  on  a  milk  diet,  and  that  a 
woman  with  a  high  nitrogenous  output  may  display  a  rapidly  in- 
creasing toxemia  with  increasing  albuminuria. 

The  treatment  of  the  eclamptic  convulsions  themselves  is  best 
dealt  with  by  considering,  first,  the  different  plans  of  treatment 
separately,  with  their  results,  so  that  their  relative  merits  may 
appear  plainly. 

Anesthetization. — Chloroform  is  the  only  anesthetic  to  be  em- 
ployed. When  this  drug  first  came  into  general  use  it  was  regarded 
by  many  as  a  specific  for  eclampsia,  and  is  so  regarded  by  a  few 
to-day.  Series  of  20,  12,  and  of  9  cases,  treated  by  chloroform 
alone,  have  been  reported  without  a  death,  Charpentier  reports 
63  cases  treated  by  chloroform  alone  with  7  deaths — a  mortality 
of  II  per  cent.  But,  on  the  other  hand,  the  mortality  from  this 
treatment  in  the  Maternite  was  50  per  cent.  The  place  of  chloro- 
form in  the  treatment  of  eclampsia  is  now  settled.  No  one  would 
rely  on  it  alone;  but  every  one  is  willing  to  admit  its  value  as  an 
adjunct  to  other  treatment. 

Diaphoresis  and  Catharsis. — Eclampsia  is  the  result  of  some 
poisonous  matter  in  the  blood,  and  can  not  be  cured  until  this 
poison  is  eliminated.  The  only  emunctories  available  for  quick 
and  effectual  action  are  those  of  tlie  skin  and  bowels.  No  matter, 
therefore,  what  plan  of  medicinal  treatment  may  be  adopted, 
diaphoresis  and  catharsis  must  also  be  employed.  The  action  of 
the  skin  may  be  excited  by  a  hot  wet-pack,  by  hot  air  or  vapor, 
or  by  a  hot  bath.  In  private  practice  the  hot  wet-pack  or  the 
hot-air  bath  are  the  most  practicable,  and  are  to  be  recom- 
mended. A  free  sweat  is  conveniently  and  quickly  produced  by 
heating  six  or  eight  bricks  on  the  kitchen  stove,  wrapping  them 
in  bath  towels,  putting  them  around  the  patient's  lower  limbs  and 
trunk,  pouring  a  pint  or  more  of  alcohol  on  them,  and  then  cover- 
ing bricks  and  patient  with  several  blankets.  There  is  nothing 
so  effective,  however,  as  the  portable  sweat  cabinet  (Fig.  510), 
with  which  every  physician  who  may  see  cases  of  eclampsia  should 
be  provided.     The  injection  of  normal  salt  solution  into  the  sub- 


DYSTOCIA   DUE    TO   DISEASE. 


637 


cutaneous  cellular  tissue  or  under  the  breasts  is  an  indispensable 
aid  to  free  elimination  by  the  skin.  It  seems  literally  to  wash  the 
blood  of  its  impurities.  If,  however,  the  patient  does  not  sweat 
or  purge  freely,  the  injection  of  salt  solution  predisposes  to  pul- 
monary edema.  Free  catharsis  is  produced  best  by  the  use  of 
croton  oil,  which  may  be  administered  in  drop  doses  with  a  little 
sweet  oil  upon  the  back  of  the  tongue,  and  can,  therefore,  be  given 
to  a  woman  whether  she  is  able  to  swallow  or  not.  Elaterium  in 
quarter-grain  tablets  may  be  administered  in  the  same  manner. 
It  is  often  advisable  to  wash  out  the  stomach;  if  this  is  done,  an 
ounce  or  more  of  castor  oil  with  a  couple  of  drops  of  croton  oil 


Fig.  510. — Turl 


abinet. 


may  be  put  into  the  stomach  through  the  stomach-pump.  If 
the  patient  can  swallow,  a  concentrated  solution  of  Epsom  salts 
is  administered,  in  dessertspoonful  doses,  every  fifteen  minutes 
until  free  catharsis  begins.  For  the  stupor  that  often  succeeds 
convulsions,  and  in  which  the  patient  frequently  dies  from  toxemia, 
the  use  of  Epsom  salts  is  most  suitable. 

Venesection. — Phlebotomy  is  at  present  somewhat  in  disfavor. 
The  reaction  against  the  indiscriminate  use  of  the  lancet  has, 
however,  gone  too  far.  While  bleeding  in  every  case  of  eclampsia 
is  unwise,  there  are  many  cases  in  which  it  rescues  women  from 
impending  danger  of  pulmonary  edema  and  apoplexy.  Physicians 
in  the  country,  who  have  to  deal  with  strong,  full-blooded  people. 


638  THE   PATHOLOGY  OF  LABOR. 

are  obliged,  in  the  treatment  of  pneumonia  as  a  routine  practice,, 
to  use  the  lancet.  In  the  same  class  of  people  blood-letting  in 
eclampsia  is  equally  necessary.  In  a  report  of  fifteen  cases  in 
which  bleeding  seems  to  have  been  the  only  thing  done,  there  was. 
but  one  death.  In  appropriate  cases  the  venesection  should  be 
done  in  time,  and  not,  as  sometimes  recommended,  only  when, 
symptoms  of  pulmonary  edema  appear.  The  measure  is  preven- 
tive of  this  accident,  not  curative. 

Morphin. — Older  statistics  of  the  morphin  treatment  for 
eclampsia  show  a  death-rate  of  57  per  cent.  (Winckel),  but  Veit 
in  more  than  60  cases  had  only  2  deaths — a  mortality  of  3.3  per 
cent.,  the  lowest  death-rate  yet  obtained  by  any  plan  of  treatment. 
This  result  is  obtained  by  giving  very  large  doses  of  the  drug.  Veit 
has  injected  one-half  grain  in  each  con\ailsive  seizure,  and  has  ad- 
ministered as  much  as  three  grains  in  four  to  seven  hours,  and  four 
and  one-half  grains  in  twenty-four  hours.  This  treatment  is  per- 
missible if,  as  is  usually  the  case  in  eclampsia,  there  is  parenchy- 
matous nephritis.  In  interstitial  nephritis  it  would  almost  surely 
kill  the  patient.^  It  also  antagonizes  the  ehminative  treatment. 
For  these  reasons  the  author  does  not  recommend  it  routinely. 

Chloral  has  many  advocates.  Charpentier  prefers  it  above 
all  others,  and  presents  statistics  to  justify  the  preference  (114 
cases,  mortality  3 5^  per  cent.).  Winckel  recommends  it 
highly,  and  by  its  use  has  saved  85  out  of  92  cases.  This 
drug,  too,  must  be  given  in  large  doses  to  be  effective.  Thirty 
to  sixty  grains  should  be  administered  by  enema  at  a  dose,  and 
as  much  as  three  drams  may  be  given  in  the  twenty-four  hours,, 
or  even  more  in  bad  cases. 

Veratnmi  Viride. — The  use  of  this  drug  is  the  American 
treatment  of  eclampsia.  For  the  past  thirty- five  years  it  has  been 
extensively  employed  in  different  parts  of  the  country,  Fearn, 
in  1 87 1,  reported  ii  cases  of  his  own  and  2  cases  from  the 
practice  of  professional  friends  treated  with  very  large  doses- 
of  veratrum  viride.  None  of  the  women  died  of  the  convulsions, 
but  one  succumbed  later  to  puerperal  sepsis.  Rushmore  has 
collected  85  cases  of  eclampsia  treated -with  veratrum  viride, 
with  20  deaths — a  mortality  of  23  ^  per  cent.  Jewett  reported 
to  the  American  Gynecological  Society,  in  1887,  22  cases  of 
eclampsia  treated  with  veratrum  viride.  Four  of  the  women  died 
of  the  convulsions — a  mortality  of  18  per  cent.  In  50  cases  of 
eclampsia  collected  by  Trimble,  veratrum  gave  much  the  best 
results.  In  26  cases  treated  by  this  drug  there  were  3  deaths,, 
while  in  the   remaining   24  cases   there  were   6  deaths — a  mor- 

1  Meyer- Wirz  found  interstitial  nephritis    three   times   in    thirty-five   autopsies- 
"Arch.  f.  Gyn.,"  Bd.  Ixxi,  H.  i. 


DYSTOCIA   DUE    TO  DISEASE.  639 

tality,  respectively,  of  11. 5  and  25  per  cent.  Mangiagalli  reports 
18  cases  treated  with  veratrum  viride  with  one  death,  not  from 
the  disease.^  I  have  used  it  in  more  than  100  cases  in  the  last 
twenty  years  and  believe  in  its  efficiency. 

Remedies  to  Reduce  Blood  Pressure. — A  rise  of  blood  pressure 
always  precedes  eclampsia,  and  increases  with  the  severity  of  the 
attack.  A  fall  in  blood  pressure,  with  amehoration  of  the  other 
symptoms,  is  the  most  favorable  prognostic  sign,  but  with  aggrava- 
tion of  the  other  symptoms  indicates  impending  death.  The 
most  successful  remedial  measures  are  those  which  reduce  blood 
pressure  most  quickly  and  most  effectually;  namely:  Puncture 
of  the  membranes;  sweating;  purgation;  venesection,  veratrum 
viride,  and  nitroglycerin. 

The  remedial  measures  detailed  above  comprise  all  that 
should  be  seriously  considered.  The  treatment  of  eclampsia 
by  antemortem  Cesarean  section,  proposed  first  by  Halbertsma, 
has  not  been  successful,  and  can  scarcely  be  regarded  as  justifi- 
able. Cafifein,  oxygen,  and  nitrite  of  amyl  have  not  been  used 
often  enough  to  justify  an  opinion  of  their  worth,  and  this  judg- 
ment must  be  passed  also  on  a  number  of  other  drugs  recom- 
mended from  time  to  time.  Pilocarpin,  as  a  routine  treatment,  is 
simply  mentioned  to  be  condemned.  There  is  no  other  treatment 
of  eclampsia  that  gives  so  high  a  mortality.  In  the  Edinburgh 
Maternity,  where  this  drug  was  employed  for  a  time,  the  mortality 
was  66.6  per  cent.  Pilocarpin  strongly  predisposes  to  pulmonary 
edema,  which  explains  the  high  mortahty.  Occasionally,  however, 
if  wet  or  dry  heat  fails  to  make  the  patient  sweat,  a  single  hypo- 
dermic injection  of  \  grain  is  of  great  service.  This  drug  is 
least  dangerous  in  eclampsia  after  delivery.  Thyroid  extract, 
recommended  by  Nicholson  as  a  vasomotor  dilator,  is  receiv- 
ing a  trial.  It  is  often  difficult  to  administer  it  if  the  woman  can 
not  swallow.  Parathyroid  extract  promises  more  satisfactory 
results  than  thyroid  extract,  and  should  be  systematically  tested.^ 
Lumbar  puncture,^  decapsulation  of  the  kidneys,  and  nephrotomy 
have  been  tried  for  eclampsia.  If  there  were  any  way  of  recog- 
nizing the  necessity  for  these  procedures  in  occasional  cases  they 
would  be  justified  once  in  a  while;  but  there  is  not,  and  if  resorted 
to  routinely  they  would  do  more  harm  than  good. 

In  eclampsia  during  parturition  the  obstetrical  treatment  must 
receive  consideration.      As   a   rule,   it  is  better  to   avoid    inter- 

i"Ann.  di  Ost.  e  Gin.,"  No.  7,  1900. 

2See  Zanprogini,  "La  Clinic.  Ostet.,"  "  Riv.  di  Ostet.,"  etc.,  anno  7,  1905; 
also,  "La  Clinic.  Ostet.,"  January,  1906  ;  Vicarelli,  "  Giorn.  d.  R.  Accad.  di  Med. 
di  Torino,"  1906.  I  am  using  it  in  i-grain  doses  every  three  to  four  hours;  if 
necessary,  given  through  the  .stomach  tube. 

■*"  Lumbar  Puncture  for  Eclampsia,"  "  Zentralbl.  f.  Gyn.,"  No.  45,  190.1.; 
"  Nephrotomie,"  ibid. 


640 


THE   PATHOLOGY  OF  LABOR. 


ference  with  the  progress  of  labor,  unless  the  os  is  fairly  well 
dilated.  Should  eclampsia  come  on  before  labor  begins  at  all,  or 
in  its  earlier  stages,  the  physician's  attention  should  be  confined 
to  combating  the  convulsions.  Having  succeeded  in  subduing 
them,  attention  may  be  directed  to  the  delivery  of  the  patient. 
It  is  usual  to  find  that  the  os  has  dilated  rapidly  during  the  con- 


Day  of 
Disease 

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103° 

102° 

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Fig.  511. — ^Temperature-chart  of  a  patient  falling  in  labor  in  the  midst  of  an  attack 
of  typhoid  fever  (author's  case). 


vulsive  attacks  or  in  consequence  of  vigorous  eliminative  treat- 
ment. It  has  been  recommended  to  resort  to  forced  delivery* 
{accouchement  force)  in  all  cases  of  eclampsia  during  labor,  resorting 
to  deep  multiple  incisions,  if  necessary,  according  to  Diihrssen's 
plan,  to  vaginal  Cesarean  section,  or  to  instrumental  dilatation  by 
Bossi's  or  other  branched  dilators.  Zweifel's  statistics  show,  it  is 
claimed,  a  mortality  of  only  15  per  cent,  in  223  cases  treated  by 
accouchement  force  as  contrasted  with  a  mortality  of  32.6  from  the 
expectant  plan.  Abdominal  Cesarean  section  has  been  performed 
in  40  cases  with  21  maternal  and  18  fetal  deaths.^     Olshausen  in 

^  Hillmann,  Sectio  Cresarea  bei  Eklampsie,  "  Monatschr.  f.  Geb.  u.  Gyn.,"'  Bd.  x. 


DYSTOCIA    DUE    TO   DISEASE.  64 1 

250  cases  of  eclampsia  has  performed  three  Cesarean  sections  with 
one  death/  It  seems  logical  to  evacuate  the  uterus  as  the  first 
step  in  the  treatment  of  eclampsia.  The  ovum  or  fetus  is  the  source 
of  the  toxemia;  many  statistics  show  a  less  mortahty  after  labor 
than  before  and  it  is  quite  a  frequent  experience  to  witness  a  cessa- 
tion of  the  convulsions  as  soon  as  the  child  is  expelled,  but  the 
necessary  operation  for  the  delivery  of  the  woman  distracts  one's 
attention  from  the  treatment  of  the  convulsions,  and  adds  for  the 
time  being  a  violent  source  of  irritation  to  the  already  highly 
wrought  nervous  system.  Eclamptic  patients  are  particularly 
liable  to  fatal  shock  from  violent  delivery  or  operative  measures 
of  any  kind.  Moreover,  by  waiting  for  a  brief  period,  during 
which  energetic  treatment  may  be  directed  to  the  convulsive 
attacks,  sufhcient  dilatation  of  the  os  is  almost  always  secured 
naturally  to  permit  the  delivery  of  the  woman  without  excessive 
violence  or  without  too  much  loss  of  time.  Puncture  of  the  mem- 
branes hastens  spontaneous  dilatation  and  lowers  the  blood-pres- 
sure more  quickly  and  effectually  than  anything  short  of  actual 
delivery;  hence,  I  resort  to  it  routinely.  As  soon  as  the  os  is  dilated 
beyond  the  size  of  a  dollar,  delivery  may  be  hastened  with  advan- 
tage by  applying  forceps  if  the  head  is  engaged  in  the  pelvis,  or 
by  performing  version  and  extraction  by  the  feet  if  the  head  is 
not  yet  engaged,  or  if  the  breech  presents.  In  eclampsia  gravi- 
darum labor  may  be  induced  after  convulsions  cease  and  the 
toxemic  symptoms  abate,  or  the  uterus  may  be  emptied  if  the  pa- 
tient fails  to  respond  to  treatment  after  a  reasonable  length  of  time. 
In  more  than  200  cases  under  my  obser\'ation  I  have  gi^'en  both 
methods  an  extensive  trial.  No  doubt  remains  in  my  mind  that 
much  the  lowest  mortality  is  secured  by  a\'oiding  any  form  of 
accouchement  force. 

It  may  be  useful  to  the  student  to  have  a  scheme  of  treatment 
for  the  average  case  of  eclampsia  that  he  can  put  into  ettect  with- 
out delay  or  confusion  from  considering  the  relative  merits  of 
the  different  plans  just  detailed.  The  following  plan  should  be 
successful  in  the  majority  of  cases:  During  the  attack  itself 
administer  chloroform.  As  soon  as  the  attack  has  ])assed  off, 
inject  under  the  skin  fifteen  drops  of  the  fluidextract  of  veratrum 
viride,  and  administer  by  the  bowel  a  dram  of  chloral  in  solution. 
Place  upon  the  back  of  the  tongue  two  drops  of  croton  oil  diluted 
with  a  little  sweet  oil.  Or,  if  ])racticable,  wash  out  the  stomacli 
and  pour  into  the  stomach-pump  2  ounces  of  castor  oil  with  2 
drops  of  croton  oil.  Give  a  thorough  sweat  for  thirty  minutes  in 
the  portable  cabinet  every  four  hours.     Ice  should  be  applied  to 

1  "  Geb.  Ges.  zu  Ikrliii,"  Nov.  24,  1S99. 
41 


642  THE   PATHOLOGY  OF  LABOR. 

the  head  while  heat  is  appKed  to  the  body.  Inject  by  gravity  under 
the  breast  or  breasts  a  pint  or  more  of  normal  salt  solution,  or, 
if  the  apparatus  for  subcutaneous  injection  is  not  at  hand,  inject 
several  quarts  of  the  solution  by  gravity  into  the  bowel.  The 
sweats  and  salt  solution  injections  should  be  alternated  every  four 
to  six  hours.  If  convulsions  recur,  nitroglycerin,  gr.  yig,  may  be 
given  every  four  hours.  If  the  face  is  congested  and  swollen, 
and  the  pulse  remains  full  and  bounding,  venesection  should  be 
resorted  to,  withdrawing  suthcient  blood  from  the  veins  to  reduce 
the  tension  of  the  pulse.  Chloral  may  be  repeated  in  the  course 
of  the  attack  two  or  three  times,  if  the  convulsions  persist  and  are 
violent.  If  the  face  is  pale  and  the  pulse  rapid  and  weak,  stimu- 
lation may  be  required  in  the  shape  of  digitalis,  strychnin,  nitro- 
glycerin, brandy,  ether,  or  ammonia  hypodermatically.  If  the  con- 
vulsions cease  and  the  patient  lies  in  a  stupor,  but  can  be  aroused 
somewhat  and  is  able  to  swallow,  concentrated  solution  of  Epsom 
salts,  in  dessertspoonful  doses,  should  be  given  every  fifteen  or 
thirty  minutes  until  free  catharsis  is  established.  If  pulmonary 
congestion  and  edema  develop,  wet  or  dry  cups  should  be  apphed 
over  the  chest.  If  the  breathing  is  stertorous,  the  face  cyanosed 
and  swollen,  wet  cups  or  leeches  should  be  applied  to  the  back  of 
the  neck  and  behind  the  ears. 

Usually  the  kidneys  recover  after  eclampsia,  but  often  a  true 
nephritis  persists  or  there  is  kidney  breakdown  in  subsequent 
pregnancies.  One  of  my  patients  had  albuminuria  and  convul- 
sions in  five  successive  pregnancies,  another  in  six.  A  woman  who 
recovers  from  eclampsia  should  be  watched  for  months  and  urinary 
examinations  should  be  made  at  intervals  for  years.  In  subse- 
quent pregnancies  dietetic  precautions  should  be  insisted  upon. 

Shock. — The  strain  of  labor  in  a  weak  woman,  some  of  the 
accidents  of  parturition,  or  even  forcible  attempts  to  expel  the 
placenta,  may  occasion  shock  after  delivery,  with  lowered  tem- 
perature, leaking  skin,  and  a  running,  rapid  pulse.  Cases  of 
this  sort  have  been  reported  from  compression  of  the  left  ovary 
in  attempts  to  expel  the  placenta  by  Crede's  method,  the  womb 
being  turned  upon  the  cervix  so  that  the  left  side  looks  forward, 
and  the  ovary  is  grasped  between  the  thumb  and  the  uterine 
wall,  when  the  hand  is  placed  on  the  fundus  of  the  womb  in  the 
effort  of  expression.  The  condition  calls  for  the  ordinary 
treatment  of  shock — heat  externally  and  stimulants  hypo- 
dermatically. 

Typhoid  fever,  pneumonia,  and  other  adynamic  diseases 
may  occur  in  pregnant  women,  and  in  the  majority  of  cases  occa- 
sion premature  deUvery.  In  typhoid  fever  this  occurs  in  sixty- 
five  per  cent,  of  the  cases,  and  in  pneumonia  the  proportion   is 


DYSTOCIA   DUE    TO   DISEASE.  643 

quite  as  large.  The  advent  of  labor  in  the  midst  of  these  diseases 
is  usually  disastrous  to  the  patient.  Profound  shock  is  often  de- 
veloped ;  the  temperature  falls  abnormally  low,  ev^en  to  95°  F., 
and  the  heart-action  may  be  extremely  weak.  Active  stimu- 
lation should  be  employed  during  the  first  stage  of  labor,  and,  as 
soon  as  the  os  is  sufficiently  dilated,  the  child  should  be  artificially 
extracted  as  rapidly  as  possible  without  serious  injury  to  the 
mother,  in  order  to  save  her  the  strain  of  voluntary  muscular 
effort  in  the  second  stage. 

Valvular  Disease  of  the  Heart. — Mitral  disease  is  the  most 
serious.  Certain  statistics  show  a  mortality  as  high  as  fifty-three 
per  cent.  As  pregnancy  advances  the  heart  becomes  more  and 
more  embarrassed,  and  respiration  more  labored.  The  most  dan- 
gerous period,  however,  is  just  after  the  expulsion  of  the  child, 
when  the  circulation  is  much  disordered  and  an  extra  quantity  of 
blood  is  thrown  back  upon  the  heart.  It  has  been  noticed  that 
when  the  discharge  of  blood  from  the  vagina  is  profuse,  cardiac 
failure  rarely  occurs.  This  clinical  observation  points  to  the  most 
successful  treatment  in  cases  of  threatened  heart-failure, — namely, 
venesection, — with  the  removal  of  from  eight  to  sixteen  ounces  of 
blood,  if  there  is  not  much  blood  lost  from  the  parturient  tract  after 
labor.  Nitrite  of  amyl  and  nitroglycerin  are  the  most  valuable 
stimulants  to  employ  during  labor  and  directly  after  its  completion. 
Digitalis  should  be  administered  hypodermatically  during  the  first 
stage  in  large  doses,  and  as  soon  as  it  is  possible  to  insert  the 
forceps  through  the  os,  or  to  grasp  the  child's  feet  if  the  head 
is  not  engaged,  the  infant  should  be  rapidly  and,  if  necessary, 
forcibly  extracted  without  anesthesia.  Deep  incisions  of  the  cervix 
are  of  the  greatest  value  in  cutting  short  the  duration  of  labor  and 
in  lessening  the  force  required  in  the  artificial  delivery  of  the  child. 
With  this  plan  of  treatment  the  mortality  of  heart  disease  in  labor 
will  Ije  much  reduced.  It  has  been  my  fortune  not  to  lose  a  case, 
although  charged  with  the  care  of  a  number,  some  of  which  were 
of  the  most  serious  character. 


PART  V. 
PATHOLOGY  OF  THE  PUERPERIUM. 


CHAPTER  I. 


Abnormalities  in  the  Involution  of  the  Uterus  after  Child-birth. 

An  abnormal  course  in  the  return  of  the  uterus  from  the  post- 
partum condition  to  the  ordinary  dimensions  and  weight  of  a  non- 
gravid  womb  may  manifest  itself  by  excess  or  by  deficiency  ;  there 
may  be  superinvolution  or  subinvolution. 

Superinvolution  is  an  abnormal  prolongation  or  an  exag- 
geration of  the  process  by  which  the  gravid  womb  returns,  after 
delivery,  to  the  dimensions  of  a  healthy  non-pregnant  uterus. 
It  is  in  consequence  reduced  to  a  size  much  smaller  than  normal. 

Trommel  detected  superinvolution  in  29  out  of  3000  cases; 
Simpson^  saw  it  in  22  out  of  1300  cases;  Sinclair,-  in  measuring  108 
uteri  after  childbirth,  found  in  22  instances  a  uterine  cavity  of  less 
than  2 1  in.  (5.7  cm.),  and  Fordyce  Barker  ^  has  declared  that  he  sees 
from  I  to  3  cases  every  year,  and  that  in  his  opinion  superinvolution 
constitutes  about  i  per  cent,  of  uterine  diseases.  Hansen,*  among 
120  nursing  women,  found  2  with  a  uterine  cavity  below  6  cm. 
(5.6,  5.4  cm.,  or  2.2,  2.1  in.)  respectively  at  the  eighth  and  tenth 
week  after  deHvery.  Johnson  ^  gives  an  account  of  3  cases  which 
occurred  in  his  practice,  and  Simpson  ^  refers  to  those  described 
by  Chiari,  Chiarleoni,  Jaquet,  and  Whitehead.  A  case  ^  has  been 
reported  after  abortion. 

1  A.  R.  Simpson,  "  Superinvolution  of  the  Uterus,"  "  Trans.  Edinburgh  Obstet. 
Soc,"  i882-'83,  viii,  p.  88. 

2  "Trans.  Amer.  Gyn.  Soc,"  vol.  iv.  This  series  of  measurements,  as  well  as 
others  made  later  by  Sinclair  and  Richardson  ("Trans.  Amer.  Gyn.  Soc,"  vols,  vi 
and  vii),  are  sharply  criticized  by  Hansen,  who  declares  them  to  be  in  great  part  in- 
correct.    The  criticism  is  apparently  merited. 

3  "Trans.  Amer.  Gyn.  Soc,"  viii,  1883;  discussion  on  Dr.  Johnson's  paper. 

*  "Ueber  die  puerperale  Verkleinerung  des  Uterus,"  "  Zeitschr.  f.  Geburtsh.  u. 
Gyn.,"  xiii,  S.  16. 

*  "Superinvolution  of  the  Uterus,"  "Trans.  Amer.  Gyn.  Soc,"  viii,  1886. 
6  Loc.  cit.  '  C.  M.  Hansen,  "  Medical  Record,"  Oct.  6,  18S8. 

644 


ABNORMALITIES  IN  INVOLUTION  OF   THE    UTERUS.    645 

The  etiology  of  the  condition  is  somewhat  obscure.  It  has 
been  ascribed  to  wasting  diseases,  as  phthisis,  cancer,  etc.;  to 
anemia  from  hemorrhage  at  a  previous  birth  or  miscarriage  ;  to 
nervous  derangements,  as  puerperal  insanity  or  chorea  ;  to  over- 
lactation  ;  to  a  rapid  succession  of  labors  ;  to  local  inflammations, 
especially  those  which  attack  the  ovaries  and  abrogate  their  func- 
tions. The  degree  to  which  the  superinvolution  may  occasion- 
ally progress  is  surprising.  A.  R.  Simpson  reports  a  case  in 
which  the  uterine  cavity  measured  but  \  of  an  inch. 

The  treatment  is  the  application  to  the  uterus  by  a  platinum 
intra-uterine  electrode  of  galvanism,  10  to  12  milliamperes,  by  the 
negative  pole ;  slow  and  rapid  interrupted  Faradism  for  fifteen  to 
twenty  minutes  every  other  day  for  six  weeks. 

Subinvolution  may  be  described  as  an  arrested  or  a  retarded 
involution  of  the  puerperal  uterus. 

Causes  of  Subinvolution. — Any  condition  which  prevents  a 
rapid  diminution  of  the  blood-supply  to  the  puerperal  uterus  may 
be  a  cause  of  subinvolution.  Any  condition  which  interferes 
with  the  contraction  of  the  uterus  is  a  cause  of  subinvolu- 
tion. It  is  necessary  to  make  these  two  broad  divisions  in  the 
etiology  of  subinvolution,  for,  although  frequently  interdepend- 
ent, they  are  not  rarely  independent  of  each  other.  In  point 
of  frequency  there  should  be  placed  first  those  causes  which  pre- 
vent the  normal  decrease  of  blood-supply  to  the  uterus  after 
labor.  Prominent  among  these  should  stand  hyperplasia  of  the 
endometrium. 

Subinvolution  by  an  excess  of  blood-supply  may  occasion- 
ally be  traced  to  the  presence  of  small  fibroids,  throughout  the 
uterine  wall.  Other  causes  of  subinvolution  are  lacerations  of  the 
cervix  and  peri-uterine  inflammations  ;  inflammations  of  the  uterine 
body  and  of  its  lining  membrane,  usually  the  result  of  sepsis  ;  re- 
tention within  the  uterus  of  placental  fragments,  shreds  of  mem- 
branes, placental  or  fibrinous  polypi,  and  blood-clots  ;  chronic  con- 
stipation; displacements  of  the  womb;  premature  getting  up; 
premature  resumption  of  sexual  intercourse  ;  and  anything  which 
interferes  with  the  return  of  the  venous  blood  to  the  heart, 
causing  a  passive  congestion  of  the  pelvic  organs,  as  increased 
intra-abdominal  pressure  from  abdominal  tumors,  certain  diseases 
of  the  liver,  and  valvular  disease  of  the  heart. 

Many  examples  of  subinvolution  by  the  mechanical  prevention 
of  perfect  uterine  contraction  may  be  observed,  as  large  intra- 
mural and  submucous  fibroids  ;  unusually  large  masses  of  hyper- 
trophied  decidua  that  sometimes  develop  at  the  placental  site  ; 
the  retention  within  the   uterus   of  considerable  portions  of  the 


646 


PATHOLOGY  OF   THE   PUERPERIUM. 


placenta,  or  placentae  succenturiatae  ;  large  blood-clots  ;  the  dis- 
placement of  the  uterus  by  a  retroversion  or  flexion  of  the  organ, 
or  by  an  overfilled- bladder  ;  peritoneal  adhesions  from  old  or 
recent  inflammatory  attacks,  involving  the  serous  covering  of 
the  uterus  and  adjacent  parts.  One  fact  stands  out  clearly 
from  an  observation  of  such  cases  :  The  cause  of  subinvolution 
is  alv/ays  some  local  disturbance,  and  not  a  constitutional  de- 
rangement. The  puerperal  state  may  be  complicated  by  any  of 
the  acute  or  chronic  febrile  affections,  without  the  slightest  in- 
fluence upon  uterine  involution.  ^ 

One  exception,  however,  must  be  made  to  this  general  state- 
ment :  nervous  derangements  do  influence  involution.  A.  R. 
Simpson  rightly  assigns  to  puerperal  insanity  a  prominent  role 
in  the  causation  of  superinvolution.  On  the  other  hand,  a  sudden 
mental  shock,  some  powerful  emotion,  may  temporarily  arrest 
involution. 

The  diagnosis  of  subinvolution  is  easy.  The  fundus  uteri  should 
be  a  finger's  breadth  above  the  umbilicus  on  the  first  day  of  the 
puerperal  state,  higher  than  it  is  directly  after  birth ;  on  the 
second  day,  at  the  level  of  the  umbilicus  ;  the  third  day,  a  little 
below  ;  the  fourth  day,  about  the  same  ;  the  fifth  and  sixth  days, 
two  fingers'  breadth  below  the  umbilicus  ;  the  seventh,  eighth, 
and  ninth  days,  three  or  four  fingers'  breadth  above  the  sym- 
physis pubis  ;  the  tenth,  eleventh,  and  twelfth  days,  at  the  level 
of  or  a  little  below  the  pubes.^  Hansen,  by  measurements  of 
120  nursing  women  from  the  tenth  day  until  the  third  month  after 
delivery,  gives  the  following  as  the  normal  course  of  involution 
from  the  tenth  day  of  the  puerperium  until  the  completion  of  the 
process  : 


Average 

Intra-uterine 
Measurement. 

Minimum. 

Maximum 

Tenth        day  1 

114  measurements)  . 

.  10.6  cm. 

8     cm. 

13.5  cm. 

Fifteenth  day 
Third     week  1 
Fourth   week 

119              '•             )  . 

95             "           )  - 
80            "           )  . 

•     9-9    " 

.    8.8    '< 
.    S.o    " 

7-5  " 
7.0  " 

II. 5     " 

10.5     " 

9-3    " 

Fifth       week 
Sixth      week 

64            "           )  . 
56            "           )  . 

•    7-5    " 
.    7.1    '- 

6.5  " 
6.2  " 

9.0  " 

9.1  " 

Seventh  week 

.40            "           )  . 

.    6.9    " 

6.0  " 

8.5    " 

Eighth   week 
Tenth     week  ( 
Twelfth  week 

31            "           )  • 

22            "           )  . 

15            "           )  • 

.    .    6.7    " 
.    6.5    " 
.    6.5    " 

5-6" 
5-4  " 
6.0  " 

8.5    " 

7-5    " 
7.5    " 

1  Temesvary  and  Backer  ("Studien  auf  dem  Gebiet  des  Wochenbettes," 
"Archiv  f.  Gyn.,"  Bd.  xxxiii,  H.  3,  S.  331,  1S88)  correctly  state  that  fever  favors 
the  involution  of  the  uterus. 

2  For  an  extensive  bibliography  of  uterine  measurements  in  the  puerperal  state 
see  .Schroeder's  "  Lehrbuch,"  8th  ed.,  1884,  p.  230,  and  Hansen,  loc.  cit. 


ABNORMALITIES  IN  INVOLUTION  OF   THE    UTERUS.    647 

In  two-thirds  of  the  cases  Hansen  found  involution  completed 
in  six  to  ten  weeks  ;  in  one-sixth,  not  until  the  last  half  of  the 
third  month  or  later  ;  in  again  a  sixth,  within  six  weeks.  The 
most  rapid  involution  occupied  four  weeks.  Any  great  deviation 
from  the  normal  course  may  easily  be  detected  by  abdominal 
palpation,  by  combined  examination,  or  by  the  use  of  a  sound, 
while  along  with  the  arrest  or  retardation  of  involution  is  usually 
found  a  profuse  lochial  discharge.  Ahlfeld^  claims  that  free  per- 
spiration after  labor  is  a  valuable  sign  of  firm  uterine  contraction 
in  the  early  part  of  the  puerperal  state  ;  when  it  fails  to  appear, 
he  always  looks  for  uterine  relaxation. 

Treatment  is  directed  not  to  the  symptom  (subinvolution),  but 
to  its  cause.  Evidently,  therefore,  it  varies  greatly.  If  the  sub- 
involution depends  upon  the  retention  of  hypertrophied  decidua,  a 
curet  promotes  rapid  involution  more  effectively  than  anything 
else.  If  placental  fragments  or  membranes  are  retained  in  iitcro, 
they  should  be  removed.  If  involution  is  retarded  by  the  presence 
of  fibroids,  the  administration  of  ergotin,  strychnin,  and  quinin  in 
pill  form,  and  the  application  of  a  faradic  current  have  given 
good  results.  The  bladder  should  never  be  allowed  to  remain 
distended  with  urine  nor  the  rectum  with  feces.  Inflammation 
in  or  about  the  uterus  must  be  combated  by  appropriate  treat- 
ment. If  the  heart-valves  are  imperfect  or  the  heart-muscle 
weak  and  the  abdominal  and  pelvic  veins  are  consequently 
engorged  with  blood,  a  heart-tonic,  as  digitalis  or  strophanthus, 
often  assists  involution.  Charpentier  has  asserted  that  the  routine 
administration  of  ergot  in  the  puerperal  state  hastens  involution. 
This  sounds  reasonable,  but  clinical  experience  has  not  borne 
out  the  statement. 

Herman  and  Fowler  ^  did  find,  in  experimenting  on  two  sets, 
of  patients, — one,  58  in  number,  receiving  an  ergot  mixture 
daily  for  a  fortnight  after  labor ;  the  other,  68  in  number, 
receiving  a  single  dose  of  ergot  after  labor, — that  in  the  first 
set  involution  advanced  more  rapidly,  but  that  there  was  no 
difference  in  the  lochial  discharge.  BoxalP  also  declared  him- 
self in  favor  of  the  routine  practice  of  giving  ergot  during  the 
puerperium,  asserting  that  in  two  series  of  cases,  comprising 
each  100, — one  treated  without,  the  other  with,  ergot, — there 
were  fewer  blood-clots  ;  they  were  more  quickly  discharged, 
and  the  after-pains  were  less  frequent,  of  shorter  duration  and 

1  "  Der  Zusammenhang  zwischen  Schweisseiuption  postpartum  und  Uteruscon- 
tractionen,"  "  Ber.  u.  Arbeit,  a.  d.  Geburts.  Gvnak.  Klinik  zu  Marbure,"  i88i;-S6, 
Bd.  iii,  S.  81. 

-"On  the  Effect  of  Ergot  on  tlie  Involution  of  tlie  Uterus,"  "British  Med. 
Jour."  1888,  i.  299.  3  Jl,iii, 


648  PATHOLOGY  OF   THE   PUERPERIUM. 

diminished  intensity  in  tlie  latter  series.  Dakin,^  however, 
dissented  from  these  views,  and  claimed,  after  testing  the 
matter  in  practice,  that  the  routine  administration  of  ergot  re- 
tarded the  involution  by  at  least  twenty -four  hours.  Blanc-  also 
declared  that  the  administration  of  ergotin  during  the  first  five  or 
ten  days  of  the  puerperal  state  has  not  a  favorable  influence  upon 
involution,  but  seems  to  interfere  wdth  it  to  some  extent.  As  it 
is  doubtful,  therefore,  whether  ergot  does  aid  involution,  as  there 
are  many  obvious  disadvantages  connected  with  its  routine  ad- 
ministration in  the  puerperal  state,  the  adoption  of  the  practice 
is  unwise,  and  is  not  to  be  recommended. 

Puerperal  anemia  might  not  inaptly  be  called  a  subinvolution 
of  the  blood.  After  the  first  twenty-four  hours  of  the  puerperal 
state  there  begins  a  change  in  the  constitution  of  the  blood  by 
which  it  is  converted  from  the  hydremia  of  pregnancy  to  the  normal 
proportion  of  its  constituent  parts  in  the  non-gravid  woman.  At 
the  end  of  two  weeks  the  process  is  so  far  complete  that  the  blood 
is  more  nearly  in  a  normal  condition  than  it  was  during  preg- 
nancy.^ Many  causes,  however,  may  disturb  the  recovery  from 
the  hydremia  and  leukocytosis  of  pregnancy.  Illness  of  any  kind 
during  pregnancy,  hemorrhage  during  labor,*  nervous  affections 
— as  insanity  or  chorea — during  the  puerperal  state,  kidney  dis- 
ease, fevers,  etc.,  may  all  induce  puerperal  anemia.  The  treat- 
ment of  the  condition  must  be  governed  by  the  circumstances  of 
the  individual  case.  The  cause  of  the  anemia  being  removed, 
the  blood  will  improve,  and  the  improvement  may  be  accelerated 
by  tonic  drugs  and  good  diet.  After  hemorrhages,  beef-tea, 
animal  soups,  milk,  and  as  nutritious  a  diet  as  the  patient  can 
bear,  along  with  tonic  medicines,  hasten  recovery.  By  the  use 
of  Blaud's  pills  I  have  seen  the  blood-corpuscles  rise  from  less 
than  three  to  nearly  four  and  a  half  million  per  cubic  milli- 
meter, and  the  hemoglobin  increase  from  forty  to  seventy-five 
per  cent,  in  a  few  weeks.  In  some  cases  arsenic  alone  suc- 
ceeds where  iron  fails.  Osier ^  has  reported  an  interesting  case 
of  the  kind. 

Treatment  of  the  Injuries  of  Child=birth. — Slight  cracks  in  the 
mucous  membrane,  small  rents  in  the  cer\ix,  \-aginal  wall,  and  vagi- 

1  Ibid.  ^  "Ann.  de  Gynec,"  March,  1888. 

'  Meyer,  "  Untersuchungen  iiber  die  Veranderung  des  Blutes  in  der  Schwanger- 
schaft,"  "Archiv  f.  Gyn.,"  Bd.  xxxi,  S.  145. 

*  It  is  extraordinary,  however,  to  see  how  rapid  occasionally  is  the  recovery  of 
puerperse,  even  from  severest  hemorrhage.  A  loss  of  2000  to  2500  grams  (4.4  to  5.5 
pounds)  of  blood  is  usually  fatal  to  an  adult,  but  Ahlfeld  reports  two  cases  in  which, 
respectively,  2000  and  2500  grams  of  blood  were  lost  without  serious  anemia  after- 
ward ("  Ber.  u.  Arb.  a.  d.  Geb.  Gyn.  Klinik  zu  Marburg"). 

5  "  Boston  Med.  and  Surg.  Journ.,"  1888,  p.  454. 


PUERPERAL   HEMORRHAGES.  649 

nal  outlet, — unavoidable  occurrences  in  almost  every  labor, — 
either  unite  firmly  or  else  are  healed  by  granulation.  Occasionally, 
very  extensive  injuries  are  repaired  by  natural  processes.  Per- 
forations of  the  vaginal  vault,  fistulous  openings  into  bladder  and 
rectum,  deep  tears  and  perforations  of  the  perineum,  transverse 
rents  and  perforations  of  the  labia,  lacerations  about  the  urethra, — 
all  have  been  known  to  unite  without  interference.  Winckel 
states  that  perineal  tears,  when  left  to  themselves,  will  be  found 
healed  in  two  and  a  half  to  five  weeks ;  by  this  he  means  that 
they  are  skinned  over  with  mucous  membrane.  The  underlying 
muscles  do  not  reunite.  Extensive  injuries  should  be  repaired, 
by  sutures  (p.  867).  Rents  in  the  vaginal  mucous  membrane 
not  involving  subjacent  muscles  and  cervical  tears  do  not  always 
require  this  treatment,  unless  there  is  profuse  hemorrhage.  In 
fistula;  the  result  of  sloughs  after  labor,  if  the  opening  is  not  too 
large,  a  cure  can  occasionally  be  effected  by  touching  the  edges 
of  the  fistula  with  a  strong  caustic,  like  nitric  acid.  To  do  this 
the  diagnosis  must  be  made  early  in  the  lying-in  period,  which, 
as  a  rule,  is  not  difficult.  The  escape  of  feces  and  gas  from  the 
vagina,  and  a  constant  trickling  of  urine,  point  respectively  to  a 
rectovaginal  or  a  genito-urinary  fistula.  It  is  necessary  in  the 
latter  case  to  exclude  the  incontinence  of  urine  due  to  paresis  of 
the  vesical  sphincter,  and  the  overflow  of  retention  sometimes 
seen  in  the  puerperal  state.  All  doubt  is  cleared  away  by  find- 
ing the  anomalous  opening  between  bladder  or  ureter  and  vagina 
or  cervical  canal.  In  abrasions  and  wounds  along  the  parturient 
tract  it  is  necessary  occasionally  to  apply  lint  saturated  with  car- 
bolized  oil  to  prevent  an  acquired  atresia  of  the  birth-canal.  If 
the  abrasions  and  wounds  are  infected  and  covered  with  exudate 
they  should  be  cauterized  with  nitrate  of  silver  solution,  .^i-fsj. 

Edema  of  the  external  genitals,  the  result  of  injuries,  pres- 
sure, or  contusions  during  labor,  gives  rise  to  considerable  pain 
and  discomfort,  which  are  best  relieved  by  the  application  of  cloths 
wrung  out  in  hot  sublimate  solution,  i :  4000.  If  the  patient's  skin 
is  irritated  by  sublimate  solutions,  I  use  hot  infusion  of  witch 
hazel. 

Puerperal  hemorrhage  denotes  profuse  bleeding  from  any 
point  along  the  genital  tract  of  the  female,  occurring  after  the  first 
day  of  the  puerperium  until  involution  of  the  uterus  is  com- 
pleted— a  period  of  about  six  weeks. 

The  causes  of  this  accident  are  numerous.  The  treatment  is 
governed  in  most  cases  by  a  knowledge  of  the  cause.  The  causes 
arc  placed,  as  far  as  ])Ossible,  in  the  order  of  their  frequency. 

Retained  placenta  and  membranes  usuallv  cause  hemor- 
rhage during  the  puerperal  state.      The  retention  of   the  whole 


650  PATHOLOGY  OF   THE   PUERPERIUM. 

placenta  is  not  now  a  cause  of  puerperal  hemorrhage,  for  no 
practitioner  of  the  present  day  would  allow  it  to  remain  within 
the  uterus  many  hours  after  delivery.  Toward  the  end  of  the 
eighteenth  and  in  the  beginning  of  the  nineteenth  century,  how- 
ever, it  was  not  rare  to  find  followers  of  William  Hunter,  who 
trusted  altogether  to  nature  to  deliver  the  placenta,  often  with 
disastrous  results.  White  ^  describes  four  cases  of  retained  pla- 
centa, with  fatal  hemorrhage  on  the  first,  second,  third,  and 
fourth  days. 

The  retention  of  placental  fragments  is  by  no  means  rare. 
A  careful  inspection  of  the  placenta  after  delivery  often  shows  a 
defect,  and  the  missing  piece  must  be  sought  and  removed  ; 
but  occasionally  it  is  difficult  or  impossible  to  tell  whether  the 
placenta  has  come  away  entire ;  and  if  the  retained  portion  is  an 
accessory  growth,  there  is  nothing  to  indicate  its  existence  in  the 
appearance  of  the  placenta  .proper.  Stadfelt  states  that,  in  70 
postmortem  examinations  of  puerperae,  placental  fragments  were 
found  in  7,  varying  from  the  size  of  a  hazel-nut  to  that  of  an 
s??-  Clinical  observation  alone  makes  this  complication  of  the 
puerperal  state  appear  more  rare.  Of  2960  births  in  the  Frauen- 
klinik  at  Munich,  from  1884  to  1887,  there  were  reported  9 
cases  of  retained  placental  fragments.^  It  is  possible,  however, 
that  small  portions  of  placental  tissue  might  escape  unnoticed 
in  the  lochial  discharge,  or  else  by  their  disintegration  form  a 
part  of  the  discharge.  The  retention  of  placental  tissue  does  not 
always  cause  hemorrhage.  I  have  seen  a  placenta  succenturiata 
expelled  on  the  second  day  of  the  puerperal  state  without  any 
previous  bleeding,  the  whole  placenta  left  in  2itero  for  twenty- 
four  hours  without  hemorrhage,  and  a  very  large  piece  of  the 
placenta  discharged  four  days  after  a  premature  birth,  very  fetid, 
but  with  no  bleeding.  In  the  9  cases  reported  by  Martini  there 
was  a  prolongation  of  the  bloody  lochia  in  i,  a  severe  hemor- 
rhage in  2  ;  in  6  there  was  no  excessive  loss  of  blood. 

The  cause  of  the  retention  of  placental  fragments  is  either 
some  abnormal  form  of  placenta  (marginata,  multiloba,  suc- 
centuriata, etc.),  an  abnormal  adhesion  to  the  uterine  wall,  or  too 
forcible  or  premature  efforts  at  extraction  or  expression.^ 

Retention  of  the  membranes  after  labor  is  of  frequent  occur- 

1  "A  Treatise  on  the  Management  of  Pregnant  or  Lying-in  Women,"  Worcester, 
Mass.,  1793,  p.  215. 

2  Martini,  "  Ueber  das  Zuriickbleiben  von  Eihaut  u.  Placentarresten  bei  vor-  u. 
rechtzeit.  Geburt,"  "  Miinchen.  med.  Wochenschr.,"  1SS8,  p.  653. 

3  Ahlfeld  in  996  deliveries  saw  only  4  cases  of  puerperal  hemorrhage.  He 
attributes  the  freedom  from  this  accident  in  his  clinic  to  his  conservative  manage- 
ment of  the  third  stage  of  labor.  He  insists  upon  waiting  one  and  a  half  hours  be- 
fore expressing  the  placenta  ("  Ber.  u.  Arbeiten,"  Marburg,  Bd.  iii). 


PUERPERAL   HEMORRHAGES.  65  I 

rence.  Martini  reports  71  cases  out  of  2960  births.^  Reihlen^ 
found  a  retention  of  some  portion  of  the  chorion  in  152  out  of 
3534  labor  cases  (4.3  per  cent.).  Another  investigation  gave 
5.1  per  cent,  from  an  analysis  of  11,381  births.  Crede^  reports 
91  cases  of  retained  chorion  in  2000  births. 

Membranes  retained  in  utero  may  give  rise  to  septic  infec- 
tion; whether  or  not  they  are  a  cause  of  puerperal  hemorrhage  is 
still  a  disputed  question.  Crede  *  believes  that  retention  of  the 
chorion  is  not  at  all  dangerous  Olshausen  declares  that  the 
retention  of  the  chorion  never  justifies  interference  to  extract  it.^ 
Reihlen^  says  that  he  never  saw  hemorrhage  as  a  result  of  re- 
tained chorion.  Schroeder^  asserts  that  retained  amnion  and 
chorion  practically  never  cause  bleeding,  even  when  retained  in 
toto.  On  the  other  hand,  WinckeP  and  Hegar'-*  have  shown 
that  retained  membranes  could  give  rise  to  puerperal  hemor- 
rhage, as  well  as  to  septicemia.  Martini  reports  28  cases  of 
retained  chorion  in  which  there  was  no  fever — that  is,  no  patho- 
logical condition,  as  uterine  inflammation,  decomposition  of 
thrombi,  etc. — to  account  for  bleeding,  and  yet  among  these 
cases  there  were  two  severe  hemorrhages,  eight  of  minor  grade, 
and  six  times  a  prolongation  of  the  bloody  lochia. 

Retention  of  hypertrophied  and  angiomatous  decidua  is 
an  etiological  factor  in  puerperal  hemorrhage.  If  the  decidua 
is  hypertrophied  during  pregnancy,  the  amount  of  tissue  re- 
tained may  be  considerable.  The  mass  may  act  as  a  foreign 
body  within  the  uterine  cavity,  preventing  firm  contraction,  and 
so  predisposing  to  hemorrhage ;  or  else,  adhering  to  the  uterine 
wall,  it  may  attract  an  unnecessary  amount  of  blood  to  the 
whole  organ,  with  the  same  result.  Even  a  small  portion  of 
deciduous  membrane,  as  well  as  shreds  of  adherent  chorion  and 
amnion,  or  placental  fragments,  may  form  the  foundation  of  poly- 
poid tumors  reaching  occasionally  considerable  size,  composed 
chiefly  of  firmly  clotted  blood  or  fibrin.  The  growth  of  these 
bodies  is  like  stalactite  formations  on  stone.  The  same  thing 
occurs  in  different  shape  when  the  placental  site  is  left  unusually 
rough  and  vascular.  The  blood  oozing  from  the  sinuses  may 
deposit  successive  layers  of  fibrin  until  quite  a  thick  mass  is 
formed. 

1  Loc.  cit. 

'^ "  Zur  Frage  der  Behancil'mg  der  Chorion-Retcntion,"  "Archiv  f.  Gyn.," 
B(l.  xxxi,  S.  56. 

'  "Arcliiv  f.  Gyn.,"  Bd.  xvii,  S.  278.  *■  Loc.  cit. 

5  "Klin.  Beilr.  zur  Gyn.  u.  Gebuitsli.,"  1884,  S.  146. 

6  L.OC.  cit.  ''  "  Lehibucli,"  10.  Autl.,  797. 
^  "  Berichte  u.  Studien,"  1S74-79;  "  P.ilh.  u.  'I'liera]).  des  ^^'ochenl)cttes." 
'"Path.  u.  Therap.  der  Placentar-Retention,"  1862. 


652  PATHOLOGY  OF   THE   PUERPERIUM. 

Prognosis  and  Treatment. — The  fact  that  a  portion  of  the 
ovum  has  been  retained  in  utero  is  usually  easy  to  discover.  A 
careful  examination  of  the  secundines  after  labor  enables  one 
to  detect  missing  parts,  which  must  have  remained  behind  in  the 
genital  tract.  It  is  not  wise,  as  a  rule,  to  invade  the  internal 
genitalia  in  order  to  remove  small  shreds  of  amnion  and 
chorion ;  if,  however,  a  greater  part  of  these  membranes  has 
been  retained,  it  is  advisable  to  remove  it.  The  diagnosis  of  re- 
tained placenta  is,  as  a  rule,  easy.  When  the  whole  organ  re- 
mains m  utero,  the  cord  dangling  from  the  external  genitals  points 
clearly  enough  to  the  condition.  If  one  or  more  cotyledons 
remain  behind,  their  absence  may  be  noted  from  the  placenta 
after  its  delivery.  Occasionally,  the  diagnosis  is  more  difficult, 
even  if  the  whole  placenta  is  retained.  I  recall  a  case  in  which  a 
woman  was  delivered  on  her  feet ;  the  child  dropped  to  the  floor, 
the  cord  was  dragged  off  from  the  fetal  surface  of  the  placenta, 
and  the  latter  remained  behind  in  the  uterus  ;  it  was  tightly 
adherent  to  the  uterine  wall,  and  its  discovery,  with  no  cord  to 
guide  one,  was  by  no  means  an  easy  matter.  It  was  finally 
peeled  off  and  extracted,  the  woman  meanwhile  bleeding 
furiously. 

Cotyledons  torn  off  the  periphery  of  the  placenta  may  easily 
go  undetected,  and  in  certain  roughly  lobulated  placentae  it  is 
very  difficult  to  be  sure  that  no  placental  tissue  has  remained 
behind.  1  If  the  medical  attendant  suspects  the  retention  of 
placental  masses  after  labor,  he  must  attempt  their  removal.  This 
is  usually  not  difficult.  The  hand, — the  only  trustworthy  instru- 
ment under  the  circumstances, — covered  by  a  sterile  rubber 
glove,  is  inserted  into  the  uterine  cavity,  the  placental  substance 
is  felt  for,  caught  by  the  fingers,  and  removed;  if  the  placenta  is 
adherent,  the  tip  of  the  finger  must  be  gently  inserted,  wherever 
most  practicable,  under  the  edge,  and  the  whole  organ  gradually 
peeled  off.  If  the  uterine  muscle  is  too  firmly  contracted  to 
allow  the  introduction  of  the  hand,  the  resistance  must  be  over- 
come by  firm,  gradual  pressure,  first  inserting  one  finger,  then 
two,  and  so  on  until  dilatation  is  effected.  To  accomplish  the 
dilatation  it  is  often  necessary  to  administer  an  anesthetic. 

If  puerperal  hemorrhage  occurs,  the  presence  of  membranes 
or  placental  fragments  within  the  uterus  should  be  suspected, 
and  their  removal  should  be  attempted  unless  some  other  con- 
dition is  clearly  seen  to  be  the  cause  of  the  bleeding.  To  reach 
the  uterine  cavity  after  involution  and  retraction  have  made  some 
progress,    it    is    often    necessary    to    dilate    the    cervical    canal. 

1  "Zur  Frage  der  Behandlung  der  Placentar-Retention,"  etc..  "  Zeitschr.  f. 
Geburtsh.,"  xvi,  pp.  292,  302. 


PUERPERAL   HEMORRHAGES. 


653 


Hegar's  bougies  will  be  found  the  safest  and  most  convenient 
instruments  for  the  purpose.  Branched  dilators,  unless  used 
with  the  greatest  care,  are  dangerous  in  the  puerperal  womb. 
Not  rarely,  however,  the  cervical  canal  remains  patulous  in  con- 
sequence of  a  foreign  body  in  utero;  in  this  case  access  to  the 
retained  mass  and  its  removal  are  easy. 


Fig.  512. — Stratz's  section  of  a  primipara,  who  died  from  hemorrhage  with  fatty 
heart  within  an  hour  after  delivery :  a,  a,  Contraction-ring  ;  i>,  b,  os  internum ; 
c,  uterovesical  reflection  of  peritoneum  ;  </,  bladder  ;  e,  symphysis  pubis;  f,  urethra; 
g,  promontory  of  sacrum  ;  //,  pouch  of  Douglas  ;   /,  posterior  fornix;  j,  os  externum. 

Displacements  of  the  Uterus. — The  dislocation  of  the  puer- 
peral uteru.s  often  manifests  itself  in  puerperal  hemorrhage. 
Inversion,  prolapse,  displacements  forward  and  backward  and 
upward  by  a  distended  bladder,  arc  all  likely  to  be  followed  by 
profuse  bloody  lochia,  if  not  by  an  active  hemorrhage.  In- 
version and  prolapse  have  already  been  considered  ;  retroversion, 
retroflexion,  and  anteflexion  are  noticed  here. 


654 


PATHOLOGY  OF   THE   PUETPERIUM. 


Hemorrhage  is  likely  to  occur  in  these  displacements  as  a 
result  of  the  passive  congestion  always  associated  with  them, 
due  to  interference  with  the  venous  circulation;  or  the  bleeding 
may  be  the  consequence  of  the  retention  of  blood  within  the 
uterine  cavity,  due  to  the  mechanical  interference  with  its  escape; 
in  the  latter  cases  clots  are  formed,  increasing  gradually  in  size, 
often  undergoing  putrefaction,  and  acting  not  only  as  a  foreign 


Fig.  513. — Section  of  a  primipara  who  died  from  sepsis  five  and  a  half  days 
after  delivery  (Barbour). 

body,  preventing  uterine  contraction,  and  attracting  by  their  irri- 
tating action  an  extra  amount  of  blood  to  the  uterus,  but  consti- 
tuting as  well  a  favorable  nidus  for  the  development  of  sapro- 
ph\-tes,  which  may  extend  their  operations  to  the  thrombi  at  the 
placental  site,  disintegrating  them.  ^ 

1  Five  cases  of  puerperal  hemorrhage  due  to  uterine  displacement  are  reported 
by  Grafe  in  "  Zeitschrift  f.  Geburtsh.,"  xii,  328. 


P  UERPERA  L   HE  MO  RRHA  GES. 


655 


The  causes  of  uterine  displacements  in  the  puerperal  state  are 
the  increased  weight  of  the  puerperal  uterus,  loss  of  tonicity,  and 
relaxation  of  the  uterine  ligaments.  They  are,  therefore,  not  in- 
frequently associated  with  subin\'olution.  Backward  displace- 
ments of  the  puerperal  womb  are  often  the  result  of  a  displace- 
ment antedating  conception.  They  are  frequently  due  also  to  a  sud- 
den physical  effort  soon  after  leaving  the  bed,  especially  if  the 
woman  has  risen  too  early,  before  involution  has  advanced  suffi- 
ciently far.  Another  common  cause  is  the  faulty  application  of  a 
compress  under  the  binder.  Many  nurses,  unless  they  are  properly 
directed,  place  a  thick  compress  in  direct  relation  with  the  anterior 
uterine  wall,  thus  crowding  the  whole  organ  backward,  instead  of 
adjusting  it   over  the  fundus  of  the  uterus,  where  it  maintains  a 


Fig.   514. — Retroflexion  of   puerperal 
uterus  (Schatz). 


Fig-  515- — Frozen  section  of  puer- 
peral uterus  in  a  state  of  anteflexion 
(Stratz). 


condition  of  anteversion,  and  b}'  constant  pressure  promotes  firm 
contraction  and  rapid  involution.  Retroversion  and  retroflexion 
may  persist  after  premature  deliver)',  if  these  displacements  ex- 
isted during  pregnancy.  Neglect  to  empty  the  bladder  at  proper 
intervals  may  be  a  cause. 

The  diagnosis  is  ea.sy  if  a  careful  physical  exploration  is 
made  ;  and  it  should  be  an  invariable  rule  to  make  a  careful 
vaginal  examination  in  every  case  of  puerperal  hemorrhage.  It 
is  not  rare  to  find  some  portion  of  the  ovum  or  blood-clots 
retained  within  the  uterine  cavity  in  consequence  of  the  "  steno- 
sis by  angulation"  of   the  cervical   canal.     It  is,  therefore,  not 


656 


PATHOLOGY  OF  THE  PUERPERIUM. 


sufficient  to  rest  satisfied  with  the  diagnosis  of  displacement  in 
puerperal  hemorrhage,  but  it  is  necessary  to  be  sure  that  there  is 
nothing  retained  within  the  uterus.  It  should  be  remembered 
that  there  may  be  no  hemorrhage,  but,  for  a  time,  suppression 
of  the  lochia,  with  displacements  of  the  womb.  Occasionally,  if 
the  dislocation  occurs  acutely,  it  may  be  associated  with  grave 
symptoms,  as  intense  pain,  a  condition  verging  on  shock,  and 
high  fever,  these  symptoms  disappearing  immediately  upon  the 
reposition  of  the  womb. 


Fig.  516. — Anteflexion.  Webster's  section  from  a  case  of  death  from  eclampsia 
about  thirty-six  hours  after  delivery:  a.  Fundus;  b,  bladder;  c,  symphysis  pubis; 
d,  promontory  ;   e,  cervix ;  f,  pouch  of  Douglas  ;  g,  vagina. 

The  treatment  of  puerperal  hemorrhage  due  to  a  displaced 
uterus  is  the  rectification  of  the  displacement,  which  is  occasion- 
ally followed  by  the  expulsion  of  blood-clots  or  remains  of  the 
ovum  imprisoned  within  the  uterus,  and  the  true  causes  of  the 
bleeding.  1  The  uterus,  restored  to  its  natural  position,  may 
remain  there.  The  knee-chest  posture  should  be  assumed  twice 
a  day.  Mechanical  supports  (tampons  and  pessaries)  are  contra- 
indicated  before  the  sixth  week. 


1  Strachan  reports  an  interesting  case  of  the  kind  associated  with  anteflexion. 
Six  weeks  after  labor  there  was  a  severe  hemorrhage ;  the  uterus  was  straightened  by 
upward  pressure  through  the  anterior  vaginal  vault.  The  following  day  a  cotyledon 
of  the  placenta  was  discharged  ("  British  Med.  Jour.,"  1886,  i,  587). 


PUERPERAL    HEMORRHAGES.  657 

Dislodgment  and  Disintegration  of  Clots  at  the  Placental 
Site. — The  thrombus  formation  in  the  large  sinuses  at  the  pla- 
cental site  plays  a  subordinate  part  in  the  prevention  of  hemor- 
rhage after  delivery.  In  consequence  of  sudden  exertion,  sitting 
upright  in  bed,  or  actually  standing  on  the  floor  soon  after 
labor,  some  of  these  clots,  plugging  up  important  vessels,  might 
be  dislodged.  It  is  with  this  possibility  in  mind  that  every  pre- 
caution should  be  taken  to  secure  quiet  and  repose  for  the 
woman  after  labor.  Disintegration  of  the  clots  at  the  placental 
site  occurs  occasionally  in  consequence  of  their  invasion  by 
micro-organisms.  This  is,  therefore,  one  of  the  phenomena  of 
puerperal  infection.  The  bleeding  that  follows  is,  of  all  puer- 
peral hemorrhages,  by  far  the  most  dangerous. 

Diagnosis. — The  hemorrhage  that  follows  displacement  of 
thrombi  at  the  placental  site  is  startling  in  its  suddenness,  and 
alarming  in  the  amount  of  blood  lost.  There  need  be  nothing 
in  the  uterine  cavity  to  account  for  it ;  the  uterus  may  be  in  good 
position.      The  true  condition  can,  of  course,  only  be  inferred. 

Treatment. — The  best  treatment  for  this  kind  of  uterine 
hemorrhage  is  the  intra-uterine  pack.^  To  tampon  the  uterus 
the  anterior  lip  of  the  cervix  is  seized  as  high  up  as  possible  with 
two  bullet-forceps;  a  strip  of  gauze  is  then  caught  by  the  end 
in  a  long  pair  of  forceps  and  is  introduced  within  the  uterus.  As 
soon  as  the  point  of  the  forceps  enters  the  uterine  cavity  the  left 
hand  grasps  the  fundus,  and  only  then  is  the  forceps  pushed  in 
as  far  as  it  will  go.  The  forceps  is  then  loosened,  withdrawn  a 
little,  a  lower  portion  of  the  gauze  strip  is  seized,  and  so  the  uterus 
is  filled  with  gauze,  lying  in  fan-shaped  folds.  The  uterus  is 
stimulated  to  contraction;  so  one  gets  the  combined  advantage 
of  a  tampon  and  a  uterine  stimulant. 

The  intra-uterine  tampon  for  hemorrhage  is  of  inestimable 
value.  There  is  no  other  means  so  absolutely  sure  to  check 
uterine  bleeding. 

Emotional  Causes. — Sudden  emotion  of  any  kind  arrests 
uterine  contraction  during  labor  and  in  the  puerperal  state. 
In  the  latter  condition  the  usual  result  is  a  hemorrhage,  which 
may  be  alarming.  Barker  *  gives  an  interesting  example  :  A 
healthy  young  primipara  almost  bled  to  death  in  the  second 
twenty -four  hours  after  labor  in  consequence  of  the  brutal  con- 
duct of  her  husband,  who  was  disgusted  that  his  child  was  a  girl. 
I  have  seen  a  sudden  and  profuse  hemorrhage  on  the  seventh 
day,  the  result  of  fright.  The  patient's  step-son  returned  home 
late  at  night  in  a  violent  state  of  intoxication. 

1  Diihrssen,  "  Die  Uterus-Taii)])onade  niit  lodofomi-Gazc  bei  Atonie  des  Uterus 
nach  normaler  Geburt,"  "  Cenlralblutt  f.  Gyii.,"  1887,  xi,  553. 
^  "The  Puerperal  Diseases,"  p.  15. 
42 


658  PATHOLOGY  OF   THE    PUERPERIUM. 

Relaxation  of  the  uterus  is  a  rare  cause  of  hemorrhage  after 
the  first  twenty-four  hours.  It  is  scarcely  ever  seen  later  than 
the  third  day,  and  when  it  occurs  after  the  first  day  it  is  in 
women  depressed  in  mind  and  body,  exhausted  by  prolonged 
labor,  weak  from  insufificient  food  or  bad  hygienic  surroundings. 
It  is  treated  on  the  same  general  principles  as  a  primary  post- 
partum hemorrhage  from  the  same  cause. 

Retention  of  blood=clots  is  usually  the  result  of  uterine  re- 
laxation, uterine  displacements,  or  a  retention  of  portions  of  the 
ovum,  around  which  the  clot  is  formed.  If  these  conditions  are 
promptly  treated,  the  retention  of  blood-clots  is  prevented.  The 
effect  of  a  large  clot  retained  in  titcro  is  often  a  hemorrhage, 
possibly  also  septicemia.  The  mass  of  clotted  blood  should  be 
removed  as  soon  as  the  symptoms  point  to  the  presence  of  a 
foreign  body  within  the  uterus. 

Fibroids. — If  the  puerperal  state  is  complicated  by  intra- 
mural or  submucous  fibroids  of  the  uterus,  there  are  certainly  a 
prolongation  and  an  increase  in  amount  of  the  bloody  lochia,  pos- 
sibly a  serious  hemorrhage.  The  latter  is  peculiarh^  liable  to 
happen  if  the  tumor  assumes  the  shape  of  an  intra-uterine  polypus. 
The  diagnosis  is  only  to  be  made  by  a  careful  physical  explora- 
tion. The  best  treatment  is  the  removal  of  the  growth  by  tor- 
sion, by  splitting  its  capsule  and  enucleation,  by  cutting  the 
pedicle  with  scissors  after  ligation  of  the  base,  or  with  the  wire 
ecraseur.  Hysterectomy  may  be  indicated.  In  small  intramural 
fibroid  tumors  in  the  puerperal  state,  ergotin,  with  styptol  (gr.  ^), 
and  strychnin,  and  the  daily  application  of  the  faradic  current,  if 
practicable,  do  much  to  secure  firm  uterine  contraction  and  prevent 
hemorrhage. 

Hematomata  along  the  genital  tract  may  burst  during  the 
puerperal  state,  with  serious  external  hemorrhage.  The  condi- 
tion is  described  elsewhere.- 

Pelvic  Engorgement. — Congestion  of  the  pelvic  blood- 
vessels may  lead  to  puerperal  hemorrhage.  The  congestion 
may  be  due  to  heart,  kidney,  or  liver  disease  ;  to  increased  intra- 
abdominal pressure  from  any  cause  ;  to  the  determination  of 
blood  toward  internal  organs  during  a  chill ;  ^  to  premature  sex- 
ual intercourse  ;  to  the  erethism  following  the  return  of  the  hus- 
band to  the  wife's  bed  ;  to  inflammation  about  the  uterus  ;  to 
subinvolution  from  any  cause  ;  to  ovarian  irritation,  and  to  con- 
stipation.   Mauriceau  ^  describes  a  case  of  puerperal  hemorrhage 

1  Winckel  ("  Path.  u.  Therap.  des  Wocbenb.")  reports  4  cases  of  this  kind  out 
of  114  of  puerperal  hemorrhage.  I  once  observed  a  striking  example  during  a 
malarial  attack  some  days  after  labor. 

^  "  Diseases  of  Women  with  Child  and  in  Child-bed,"  translated  by  Hugh  Cham- 
berlen,  London,  1752. 


PUERPERAL    HEMORRHAGES.  659 

that  continued  quite  profusely  for  five  or  six  days,  and  which 
was  only  checked  when  "  a  pretty  strong  clyster  "  resulted  in  the 
evacuation  of  "  a  panful  of  gross  excrements." 

Wounds  in  the  Genital  Tract. — Secondary  hemorrhage  may 
occur  from  wounds  in  the  cervix,  vagina,  and  vulva.  Occasion- 
ally, abnormally  large  blood-vessels  are  injured  in  these  regions. 
On  one  occasion  I  saw  a  hemorrhage  from  an  anomalous  artery 
in  the  perineum  that  nearly  proved  fatal.  It  is  possible  that  a 
vessel  of  considerable  size  might  be  wounded  during  labor,  and 
yet,  in  consequence  of  pressure  from  the  child's  head  or  of  an 
unstable  plug  of  clotted  blood,  would  not  bleed  until,  at  some 
time  in  the  puerperal  state,  the  tissues  recovering  their  tone  or 
the  clot  being  dislodged  hemorrhage  would  occur. 

The  diagnosis  is  easily  made  if  the  parts  are  exposed  to  view. 
The  bleeding  vessel  may  be  detected  and  should  be  ligated. 

Carcinoma  of  the  Corpus  Uteri  and  of  the  Cervix. — Carci- 
noma (syncytial)  or  sarcoma  may  develop  at  the  placental  site 
during  the  puerperium.  Epithelioma  of  the  cervix,  if  at  all  ad- 
vanced, will  surely  cause  some  hemorrhage.  The  best  treatment 
for  the  immediate  control  of  hemorrhage  from  this  cause  is  a 
uterine  or  a  vaginal  tampon.  Hysterectomy  should  be  performed, 
if  possible,  without  delay.  In  inoperable  cases  with  uncontrollable 
hemorrhage,  ligation  of  the  internal  iliac,  the  ovarian,  and  the  round 
ligament  arteries  is  indicated. 

Rare  causes  of  puerperal  hemorrhage  are  rupture  of  the 
uterine  artery,  reported  by  Hewitt,  ^  with  a  fatal  result  six 
weeks  after  labor;  the  rupture  of  a  distended  vein  in  the  cervix, 
followed  by  fatal  bleeding,  described  by  Hecker.^  Meschek^ 
reports  a  similar  case,  with  like  result,  due  to  an  eroding  ulcer 
which  opened  a  large  vessel  in  the  cervix.  Johnston  has  re- 
ported a  fatal  puerperal  hemorrhage  due  to  rupture  of  a  hema- 
toma of  the  cervix.  4 

Puerperal  Hematoma. — A  form  of  hemorrhage  in  the  female 
genitalia  during  or  after  labor,  much  more  rare  than  the  second- 
ary hemorrhages  just  described,  is  an  interstitial  effusion  of  blood, 
with  the  consequent  formation  of  a  blood-tumor,  varying  in  size 
with  the  degree  of  the  hemorrhage.  Levret  seems  to  have  been 
familiar  with  the  accident,  but  with  this  exception  a  knowledge 
of  the  nature  of  hematoma  in  pucrpcraj  has  been  acquired  in  quite 
recent  times.  The  first  systematic  treatise  on  the  subject  is 
Deneux's  monograph. '"^     It  was  also  fully  described  by  Dewees.  ^ 

'  "  London  01)stet.  Trans.,"  vol.  ix.  -  "  Archiv  f.  Gyn.,"  Bd.  vii,  S.  2. 

^  "  Zeitsclir.  d.    Hes.  d.  Wien.  Aerzte,"  lS54'  ''■ 

*  Sinclair,  "  Pract.  of  Midwifery,"  1S5S,  p.  501. 

5  "  Tumeurs  sanguines  de  la  Vulve  et  du  \'agin,"  Paris,  1830. 

"  "  Midwifery." 


66o  PATHOLOGY  OF   THE   PUERPERIUM. 

The  accident  is  rare,  but  individual  experience  differs  widely 
as  to  its  frequency.  Deneux  was  able  to  collect  62  cases,  but  had 
himself  only  seen  3  in  a  practice  of  fourteen  years.  Paul  Dubois 
saw  but  I  case  in  14,000  labors.  Velpeau,^  writing  five  years  after 
the  appearance  of  Deneux's  article,  declared  that  it  would  be  easy 
to  collect  the  detailed  accounts  of  100  cases;  that  he  himself  had 
seen  25.  Barker,  of  New  York,  reported  22  cases  that  came  under 
his  personal  observation.  Winckel  quotes  McChntock's  claim  that 
he  had  observed  25  cases,  and  places  an  exclamation  mark  after  the 
quotation,  evidently  as  a  sign  of  incredulity.^  The  former  has 
only  met  with  6  well-marked  cases  in  an  experience  of  almost 
20,000  confinements.  Bossi  found  hematomata  twice  among 
5660  women  in  child-bed;  Hugenberger,  11  times  in  14,000 
deliveries;^  in  Vienna  it  was  noted  18  tim-es  out  of  33,241  births.* 
This  would  indicate  a  frequency  of  i  to  1600  births. 

The  situation  is  most  frequently,  by  far,  in  one  or  the  other 
labium  majus,  rarely  in  both.  The  blood-tumor  may,  however, 
occupy  a  position  beneath  the  vaginal  wall,  on  either  side,  poste- 
riorly or  anteriorly;  in  the  ischio-rectal  fossa;  in  the  labia  minora; 
in  the  caruncul^e  myrtiformes;  under  the  skin  of  the  perineum,  be- 
tween the  superficial  and  median  fascia;  in  the  cervix;  in  the  peri- 
uterine connective  tissue;  within  the  broad  ligament;  in  the  sub- 
peritoneal connective  tissue,  on  the  posterior  and  anterior  abdomi- 
nal walls,  extending  as  high  as  the  kidneys  and  navel  (Cazeaux, 
Hugenberger,  Winckel) ;  under  the  skin  of  the  mons  veneris  or  over 
the  inguinal  ring  (Velpeau).  If  the  effusion  occurs  above  the  pelvic 
fascia,  the  blood  forces  its  way  upward  toward  the  diaphragm  ; 
if  below,  downward  toward  the  vulva. 

Size  and  Form. — Small  extravasations  of  blood  are  to  be  met 
with  along  the  genital  tract  very  frequently  after  labor  ;  this  form 
of  thrombus  is  due  to  the  fact  that  the  mucous  membrane  is 
pushed  in  front  of  the  presenting  part  with  a  glacier-like  move- 
ment over  the  underlying  tissues,  and  there  thus  occurs  a  lacer- 
ation of  the  submucous  connective  tissue  and  the  small  blood- 
vessels contained  in  it.  A  careful  examination  often  reveals 
numerous  hematomata  after  labor,  varying  in  size  from  that  of  a 
pigeon's  tg^  to  that  of  a  walnut.  It  is  the  larger  tumors  that 
are  rare.  They  may  vary  in  size  from  that  of  a  hen's  &^^  to 
that  of  a  child's  head ;  in  extreme  cases,  if  the  blood  is  diffused 
throughout  a  great  part  of  the  subperitoneal  connective  tissue, 

1  "  Traite  complet  de  TArt  des  Accouchements,"  Brussels,  1835. 

^  "  Lehrbuch  der  Geburtschlilfe,"  1889. 

^  "  Hiematoma  Vulvae  im  Verlauf  der  Schwangerschaft,"  "Archiv  f.  Gyn.,"  Bd. 
xxxiv,  H.  I. 

*  These  latter  statistics  are  taken  from  Winckel' s  book,  where  a  reference  to  the 
original  authorities  may  be  found. 


PLATE   T?. 


Ileiiiatnnia  of  the  vulva  (aulhdr's  rase) 


PUERPERAL    HEMORRHAGES.  66 1 

the  size  of  the  effusion  would  be  very  large  were  the  blood 
contained  within  a  limited,  circumscribed  tumor. 

In  shape,  blood-tumors  of  the  genital  tract  may  be  globular; 
in  the  cervix  they  distend  the  tissues  of  one  or  both  lips  down- 
ward and  outward,  giving  to  the  cervix  the  form  of  a  shark's 
nose.  In  the  vagina  they  may  hang  from  the  anterior  or  posterior 
wall  in  the  form  of  a  polypus  (Fleischmann).  In  the  labia  the 
hematoma  is  sausage-shaped  (see  Plate  14). 

Etiology. — The  predisposing  causes  of  puerperal  hematomata 
are  the  engorged  condition  of  the  blood-vessels  along  the  genital 
tract  and  the  strain  that  is  imposed  upon  them  either  by  the 
pressure  of  the  fetal  body  or  by  the  great  muscular  effort  put 
forth  during  labor.  The  more  engorged  the  vessels  are,  the 
more  likely  is  the  occurrence  of  hematoma.  Halliday  Croom"- 
attaches  great  importance  to  anteversion  of  the  parturient  uterus 
as  a  predisposing  cause  of  vaginal  hematoma,  believing  that  thus 
an  excessive  strain  is  put  upon  the  whole  posterior  vaginal  wall, 
and  a  rupture  of  distended  blood-vessels  in  this  region  is,  therefore, 
more  probable.  Hypertrophic  elongation  of  the  cervix  certainly 
predisposes  to  the  formation  of  hematoma  in  that  region  during 
and  after  labor.  The  determining  cause  of  the  accident  may 
be  a  direct  injury  to  the  tissues  by  forceps,  a  fall  or  a  blow,  or 
the  violent  straining  efforts  during  the  second  stage  of  labor. 
In  the  majority  of  cases,  however  (86  per  cent.,  Winckel),  the 
occurrence  of  hematomata  is  apparently  spontaneous.  The  im- 
mediate cause  of  hematoma  is  the  rupture  of  a  blood-vessel  and 
the  interstitial  extravasation  of  blood;  the  vessel  injured  is  com- 
monly a  vein,  not  rarely  of  large  size.  Possibly  a  number  of  smaller 
vessels  may  be  ruptured.  The  injury  to  the  blood-vessels  is  either 
a  direct  and  immediate  laceration,  or  else,  later,  a  perforation  by 
pressure  necrosis. 

Clinical  History  and  Diagnosis. — The  interstitial  hemorrhage 
that  results  in  a  hematoma  begins,  with  rare  exceptions,  during 
labor.^  The  extravasation  of  blood  may  at  first  be  gradual,  so 
that  it  does  not  attract  attention  until  some  time  in  the  puer- 
peral state.  The  distention  of  the  vagina  by  the  presenting  part 
of  the  fetus  may  prevent  all  bleeding  until  the  maternal  tissues 
are  relieved  of  pressure.  If  the  bleeding  results  from  necrosis 
of  tissue,  the  result  of  prolonged  pressure,  the  formation  of  a 
hematoma  may  first  begin  after  delivery.  In  cases  in  which  the 
accident  has  seemed  to  be  the  result  of  violent  coug-hincT  or  other 
exertion  during  the  child-bed  period,  there  had  been,  no  doubt, 

'  "On  the  Etiology  of  Vaginal  Hematoma  Occurring  During  Labor,"  "Edin- 
burgh Med.  Jour.,"  vol.  xxxi,  pt.  ii,  p.  looi. 

''■  Vinay  reports  a  case  in  the  sixth  month  of  pregnancy  after  an  epileptic  lit, 
"Centralbl.  f.  Gyn.,"  No.  7,  1897. 


662  PATHOLOGY   OF   THE    PUERPERIUM. 

some  injury  done  the  vessels  during  parturition.  The  sub- 
cutaneous or  submucous  laceration  of  tissue  occurring,  as  a  rule, 
during  the  second  stage  of  labor  is  almost  always  associated 
with  acute  pain  of  a  sharp,  lancinating  character,  quite  different 
from  labor-pains.  The  suffering  increases  as  the  hematoma 
enlarges,  and,  in  addition  to  the  sharp  pain  of  torn  tissue,  there 
are  exaggerated  and  painful  expulsive  efforts  excited  by  the 
presence  of  the  tumor  within  or  alongside  the  vagina.  This  is  an 
almost  constant  symptom,  but  Barker  reports  a  painless  case.  The 
hemorrhage  into  the  tissues  may  be  profuse  enough  to  occa- 
sion the  most  marked  signs  of  acute  anemia.  Pallor,  failure  of 
vision,  a  thready  pulse,  air-hunger,  loss  of  consciousness,  and, 
finally,  death,  may  all  be  noted  without  the  slighest  external 
escape  of  blood.  An  examination  of  the  patient  shows  a- tumor 
occupying  the  situations  already  described,  of  varying  size,  and 
differing  in  consistency  as  the  blood  contained  in  it  is  fluid  or 
clotted.  If  the  hematoma  is  submucous,  it  presents  a  dark,  pur- 
plish color,  like  clotted  blood.  If  it  is  covered  with  skin,  it 
presents  a  bluish,  ecchymotic  hue,  although  in  the  labium  majus 
the  color  may  be  the  same  as  in  a  submucous  hematoma.  As  a 
rule,  the  swelling  only  appears  after  labor.  It  may,  however, 
occur  before  the  expulsion  of  the  child,  and  it  has  repeatedly 
developed  between  the  birth  of  twins.  ^  If  the  tumor  is  formed 
during  labor,  it  may  present  a  formidable  obstacle  to  delivery  ;  if 
it  appears  in  the  puerperal  state,  it  may  dam  back  the  lochia  or 
give  rise  to  dysuria  or  to  retention  of  feces.  With  the  history 
of  a  sharp  attack  of  pain  during  labor,  the  subsequent  rapid  de- 
velopment of  a  tumor  along  the  genital  tract  characteristic  in  its 
appearance  and  situation,  the  signs  of  internal  hemorrhage,  the 
diagnosis  of  the  true  condition  ought  not  to  be  difficult ;  and  yet 
a  mistake  is  quite  possible. 

Puerperal  hematoma  has  been  confused  with  varicose  tninoTS 
of  the  labia,  inguinal  hernia,  and  inversion  of  the  vagina.  Once 
in  Barker's  experience  a  vaginal  hematoma  was  mistaken  for  a 
fetal  head,  and  once  iox  placenta  prcBvia.  Auvard-  says  that  on 
first  sight  he  took  a  hematoma  o  f  the  anterior  lip  of  the  cervix 
for  a  clot  of  blood  lying  in  the  vagina.  The  Barneses,^  in 
describing  their  case  of  cervical  hematoma,  write  that  they  found 
a  fleshy  tumor  projecting  from  the  vulva  which  looked  like  a 
mass  of  coao-ulated  blood,  or  which  migrht  ha\'e  been  mistaken  for 
an  inverted  itteriis.  The  diagnosis  is  more  difficult  in  cer- 
vical   hematomata    than    in    those    of  the   lower  genital   canal. 

1  One  case  reported  by  Dewees  ("  Diseases  of  Females,"  "  Of  Bloodv  Infiltra- 
tion in  the  Labia  Pudendi"),  and  six  by  Madame  Sasanoff  ("  Annales  de  Gyne- 
cologie,"  December,  1884).      Four  of  these  latter  cases  died. 

2  "Trav.  Obstet.,"'  Paris,  i88g,  t.  i,  p.  440. 

3  "  Sys.  of  Obst.  Med.  and  Surg,"  Philadelphia,  1885. 


PUERPERAL    HEMORRHAGES.  663 

The  former  are  rare.  Besides  the  two  just  mentioned,  others 
are  described  by  Hohl,  Braun,  Earle  (two  cases),  and  Winckel.^ 
Hematomata  along  the  genital  canal  may  burst  soon  after 
their  formation,  with  appalling  and  possibly  fatal  hemorrhage. 
In  cases  of  labial  tumors  the  point  of  rupture  is  likely  to 
be  the  boundary-line  between  the  greater  and  lesser  labia. 
A  hematoma  within  the  pelvis  may  open  into  the  peritoneal 
cavity,  with  fatal  hemorrhage.^  In  one  case  under  my  obser- 
vation a  large  hematoma  formed  between  the  layers  of  the 
broad  ligament.  Four  hours  later  the  posterior  layer  of 
the  broad  ligament  ruptured,  the  bleeding  became  intraperi- 
toneal and  unlimited,  and  the  patient  died  before  I  reached 
her.  After  early  rupture  or  primary  incision  of  the  tumor, 
profuse  hemorrhage  is  likely,  and  secondary  bleeding  is  apt  to 
occur.  This  accident  is  rare  when  the  tumor  is  opened  after 
bleeding  into  it  has  ceased. 

Winckel  has  thus  summarized  the  terminations  of  puerperal 
hematoma:  (i)  Death  by  hemorrhage  with  or  without  previous 
rupture  of  the  tumor  ;  (2)  death  following  suppuration  of  the  sac 
and  septicemia,  most  frequently  after  the  sac  has  been  opened  ; 
(3)  rupture  of  the  tumor,  with  recovery ;  (4)  rupture  of  the 
tumor,  with  a  resulting  fistula;  (5)  perfect  recovery  by  absorp- 
tion of  effused  blood,  without  rupture  of  the  sac.  In  fifty  cases 
collected  by  Winckel  from  modern  literature  the  tumor  burst 
spontaneously  in  the  first  eight  days  in  twenty-three.  A  hema- 
toma may  be  evacuated  not  only  by  escape  of  the  contained 
blood  externally,  but  by  diffusion  of  its  contents  under  the  skin. 
Dill  ^  reports  a  case  of  large  hematoma  of  the  right  labium, 
which  ruptured  internally  and  produced  ecchymoses  reaching 
to  the  nates  and  to  the  right  knee,  to  the  umbilicus,  and  even 
as  high  as  the  right  axilla.  Suppuration  may  occur  in  a  blood- 
tumor  that  has  not  been  ruptured  at  all,  and  the  effused  blood 
may  be  converted  into  a  large  accumulation  of  pus.  As  these 
abscesses  are  often  in  the  neighborhood  of  the  rectum,  the  pus 
may  acquire  a  fecal  odor,  without  a  communication  with  the 
bowel.  A  rectovaginal  fistula  may  result  if  the  hematoma 
breaks  its  way  into  the  rectum  and  also  opens  anteriorly  into  the 
vagina.  Suppuration  is  most  to  be  feared  after  the  blood-tumor 
is  opened  and  its  cavity  is  exposed  to  the  contamination  of  the 
atmosphere  and  of  the  lochial  discharge. 

Prognosis. — The  formation  of  a  hematoma  during  or  after  labor 
was  formerly  regarded  as  a  more  dangerous  complication  than  it 
is  considered  to-day.  Of  Deneux's  62  cases,  22  died.  Fatal 
cases  have  been  reported  by  Cazeaux,  Lubanski,  Broers,  Seulen, 

1 "  Lehrbucli,"  1889.  -Williams,  "Am.  Jour,  of  Ohstet.,'^  Oct.,  1904. 

""  Dublin  Jour.  Med.  Sci.,"  November,  1886. 


664  PATHOLOGY  OF   THE  PUERPERIUM. 

Josenhans,  Hugenberger,  Braun,  and  the  author.  The  causes 
of  death  in  these  cases  were  hemorrhage  (in  two  instances  into 
the  peritoneal  cavity),  septicemia,  and  typhoid  fever  (?).  Blot 
collected  19  cases  since  Deneux's  paper  was  published,  with  5 
deaths,  Perret,  in  an  analysis  of  43  cases,  found  17  deaths.  Of 
II  cases  observed  by  Hugenberger,^  4  died.  Girard,^  in  an 
analysis  of  120  cases,  found  24  deaths.  Johnston  and  Sinclair* 
report  7  cases  during  seven  years'  service  in  the  Dublin  Rotunda, 
with  2  deaths.  Scanzoni  met  with  15  cases,  i  of  which  died. 
Winckel,  among  50  cases,  found  only  6  deaths.  Of  the  6  cases 
in  his  personal  experience,  not  one  died.  Barker  reports  22  cases 
of  his  own,  of  which  2  died.  Barnes*  reports  2  cases  with  a 
favorable  issue  ;  Auvard,^  i  of  cervical  hematoma  that  disap- 
peared by  absorption.  Groom's  3  cases  all  recovered.  Death 
from  a  puerperal  hematoma  at  present  should  be  rare,  especially 
if  the  patient's  general  condition  is  good  and  her  hygienic  sur- 
roundings are  satisfactory. 

Treatment. — If  the  hematoma  is  of  moderate  size,  not  larger 
than  one's  clenched  fist,  the  main  object  of  treatment  is  to  secure 
absorption  of  the  effused  blood,  and  thus  the  disappearance  of 
the  tumor.  It  may,  however,  be  necessary  to  remove  an  ob- 
struction to  labor  if  the  tumor  develops  before  delivery ;  to  con- 
trol the  hemorrhage  either  before  or  after  rupture  of  the  sac  ;  to 
treat  the  general  symptoms  of  profuse  bleeding  ;  to  evacuate  the 
contents  of  the  sac  when  suppuration  has  occurred,  and  to  pre- 
vent septic  infection. 

To  secure  the  disappearance  of  a  hematoma  by  absorption 
cleanliness  of  the  parts  and  rest  are  necessary.  If  the  tumor 
is  vaginal  or  cervical,  frequent  irrigation,  of  the  vagina  is  ad- 
visable. If  the  effusion  is  subcutaneous,  cooling  lotions  and 
inunctions  with  carbolized  oil  often  prevent  inflammation  and 
rupture  of  the  sac.  If  the  tumor  appears  before  or  during  labor, 
and  offers  an  obstacle  to  the  delivery  of  the  child,  it  must  be 
freely  opened  ;  the  contents,  whether  fluid  or  clotted  blood, 
evacuated  ;  pressure  exerted  by  a  tampon  of  iodoform  gauze,  in 
order  to  check  the  hemorrhage  ;  while  the  extraction  of  the 
infant  by  forceps  or  after-version  is  hastened  as  much  as  pos- 
sible. To  control  the  hemorrhage  into  the  tissues  before  exter- 
nal rupture  has  occurred,  pressure,  cold,  and  the  internal  admin- 
istration of  ergot  may  be  tried.  An  ordinary  tampon  in  the 
vagina  is  not  admissible,  for  it  would  dam  back  the  lochial  secre- 
tion, and  would  become  foul.      Braun's  colpeurynter,  or  a  large 

^  "  St.  Petersburg  med.  Zeitung,"  1865. 

^  "Contribution  a  I'etude  des  Thrombes  de  la  Vulve  et  du  Vagin  dans  leurs 
Rapports  avec  la  Grossesse  et  rAccouchement,"  "  These  de  Paris,"  1874. 

^  Barker,  loe.  cit.  *  Loc.  cit.  5  Loc.  cii. 


NON-INFECriOUS   FEVERS.  665 

Barnes'  bag,  distended  with  ice-water,  is  the  best  appliance,  for 
it  can  be  easily  removed  at  frequent  intervals  to  allow  an  anti- 
septic irrigation  of  the  vagina.  If  it  is  possible  to  avoid  it,  the 
tumor  should  not  be  opened  while  it  is  increasing  in  size,  for 
there  may  be  profuse  hemorrhage  at  the  time  and  a  secondary 
bleeding  later.  This  does  not  occur,  as  a  rule,  when  the  tumor 
is  incised  after  the  effusion  ceases,  and  yet  there  are  two  cases 
on  record  in  which  hemorrhage  occurred  from  tumors  opened 
one  and  three  weeks  after  their  formation.  ^  If  the  tumars  are 
too  large  to  be  absorbed,  or  if  there  is  threatened  gangrene  of 
their  coverings,  they  should  be  opened. 

Hematomata  may  burst  within  the  first  few  days  after  their 
formation,  and  there  may  be,  in  consequence  of  the  rupture,  an 
alarming  hemorrhage.  In  such  cases  it  is  best  to  enlarge  the 
opening  ;  to  turn  out  the  clots  within  the  tumor  ;  to  search  for 
the  bleeding  vessels,  which  may  be  seen  spurting  from  the  walls, 
and  to  apply  a  ligature.  If  this  is  impossible,  and  bleeding  still 
continues,  the  cavity  may  be  firmly  packed  with  iodoform  gauze, 
firm  external  pressure  being  exerted  by  a  large  pad  and  a  T- 
bandage.  The  styptic  salts  of  iron  should  not  be  applied,  for 
such  a  firm,  dense  clot  is  thus  formed  that  it  takes  a  long  time 
for  it  to  disintegrate,  the  woman  meanwhile  running  a  risk  of 
septicemia. 

After  the  coverings  of  a  hematoma  are  incised  or  ruptured, 
suppuration  commonly  occurs  in  the  cavity;  septicemia  must 
be  avoided  in  such  cases  by  an  iodoform  tampon  in  the  ab- 
scess cavity  often  renewed,  and  by  frequently  repeated  irri- 
gations. Suppuration  may  occur  before  the  tumor  has  been 
opened  at  all.  In  such  cases  the  pus  must  be  evacuated.  The 
opening  should  not  be  delayed  too  long,  especially  in  suppu- 
rating hematomata  of  the  posterior  vaginal  wall,  or  fistulae  may 
result.  The  general  treatment  for  loss  of  blood  is  to  be  con- 
ducted in  the  ordinary  manner  when  the  indications  call  for  it — 
hypodermatics  of  ether,  brandy,  and  other  stimulants ;  hot  ani- 
mal broths  internally;  "auto-infusion"  by  bandaging  the  limbs; 
and  subcutaneous  or  intravenous  injections  of  a  normal  salt 
solution. 

Non=infectious  Fevers. — Fever  in  the  puerperal  state  not  due 
to  infection  may  arise  from  emotion,  from  exposure  to  cold, 
from  constipation,  from  reflex  irritation  of  any  kind,  from  cerebral 
disease,  from  eclampsia,  from  insolation,  from  syphilis,  from  the 
exacerbation  or  persistence  of  an  acute  or  chronic  disease  con- 
tracted during  or  before  pregnancy. 

Emotional  Fever. — ^That  fever  may  appear  in  consequence  of 
emotions,  clinical  evidence  leaves  no  doubt.     The  cause  of  the 

^  Parvin's  "  (Jbstelrics,"  p.  502. 


666 


PATHOLOGY  OF   THE   PUERPERIUM. 


fever  being  transient,  perhaps  momentary,  the  elevated  tempera- 
ture quickly  sinks  to  normal.  It  is  not  in  every  person  that  power- 
ful emotions  are  followed  by  an  elevation  of  temperature  to  a  note- 
worthy degree.  There  m^ust,  apparently,  be  predisposing  causes 
ill  the  nervous  system  of  the  individual.  Emotional  fever  is  most 
often  met  with  in  children,  in  hysterical  girls,^  and  in  wom:en  after 
child-birth.  In  child-bed  there  is  a  curious  irritability  of  the  or- 
ganism, a  lack  of  control  over  the  micntal  processes. 

Hunt's^  records  of  seventy-five  cases,  confined  to  women  free 
from  infection  and  inflammation,  in  which  the  temperature  was 


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Fig.  517. — Chart  of  emotional  fever  from  dread  of  an  operation. 

taken  twice  a  day  in  the  month,  gives  three  apparently  t}'pical  ex- 
amples of  fever  from  emotion.  I  have  seen  a  number  of  examples 
of  emotional  fevers.  Failure  to  receive  an  expected  letter,  fear  of 
exposure  in  illegitimate  pregnane}',  the  expected  removal  of 
the  woman's  infant  to  an  asylum,  dread  of  an  operation,  and  a 
variety  of  mental  disturbances  have  given  rise  in  my  experience 
to  a  high  but  transitory  fever.  Figure  517  shows  the  tempera- 
ture record  of  a  t}'pical  case.  There  had  been  an  operation  for 
mammary  abscess  in  a  hospital  ward.  It  was  witnessed  by 
two  puerperal  patients.  One  of  them,  a  young  girl,  shoitly 
after  experienced  pain  in  the  breast.  She  at  once  conceived  a 
morbid  dread  of  an  operation  in  her  own  case.  The  beginning 
elevation  of  temperature  in  the  chart  indicates  the  commence- 
ment of  engorgement  and  pain  in  the  breast.  These  symptoms 
continued  for  a   few  days,  when,   after    lying    awake   all   night 

1  The  case  reported  by  Dr,  Matomed  is  a  famous  example  ;  the  temperature  is 
said  to  have  reached  128°  F.  C  Lancet."  1881,  vol.  ii,  p.  790). 

^"Normal  Course  of  Puerperal  Temperature,"  "Practitioner,"  London,  1S8S, 
p.  81. 


A'OiV- INFECTIO  US  FE  VERS. 


667 


brooding  on  the  subject,  the  girl's  temperature  began  to  rise  in 
the  morning,  finally  reaching  the  height  indicated  on  the  chart. 
The  only  antipyretic  employed  was  the  emphatic  assurance  of  the 


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Fig.  518. — Chart  of  fever  case  from  exposure  to  cold.  The  patient  left  her  bed 
twice  against  orders,  in  her  bare  feet  and  night-gown.  Each  time  there  was  a  rise 
of  temperature,  quickly  subsiding. 


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Fig.  519- — Chart  of  a  woman  constipated  for  six  days  in  the  latter  part  of  tlie 
puer])eral  state.  There  had  been  one  movement  of  the  bowels,  five  days  after  labor, 
and  then  none  for  six  days.  A  large  dose  of  castor  oil  and  an  enema  reduced  the 
temperature  to  normal  in  a  few  hours. 

resident  physician  that  tlicrc  was  not,  and  would  not  be,  the 
slightest  excuse  for  an  incision  in  the  breast.  The  patient's  fears 
being  allayed,  her  temperature  quickly  sank  to  normal,  where  it 
remained. 


668 


PATHOLOGY  OF  THE   PEURPERIVM. 


Fever  from  Exposure  to  Cold. — In  the  sensitive  condition  of 
puerperse  it  is  not  uncommon  to  see  a  febrile  reaction  follow  undue 
exposure.  A  careless  nurse  or  attendant  may  be  responsible  for 
too  low  a  temperature  in  the  lying-in  room,  or  for  ill-regulated 
ventilation,  or  for  insufficient  or   ill-arranged    bed-clothing.      A 


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Fig.  520. — Reflex  fever  from  mammary  congestion.     *  Breast  incised  without 

finding  pus. 

wilful  patient  may  leave  her  bed  too  soon  and  expose  herself, 
thinly  clad,  to  cold  (Fig.  518). 

Fever  from  Constipation. — The  temperature-chart,  figure  519, 
is  that  of  a  woman  in  the  Philadelphia  Hospital  who  had  had  but 
one  evacuation  of  the  bowels — on  the  fifth  day — in  the  eleven  days 


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Fig.  521. — Fever  followed  by  expulsion  of  tape-worm.     *  Tenia  passed  from  bowel. 

succeeding  delivery.  The  temperature  fell  immediately  after  a 
large  dose  of  castor  oil  and  the  administration  of  an  enem_a,  which 
produced  an  enormous  fecal  evacuation. 

Fever  from  Reflex  Irritation. — Physical  irritation,  as  well  as 
psychical,  may  be  reflected  in  general  elevation  of  the  body- 
temperature  during  the  puerperal  state.     The  irritating  point  is 


NON-INFECTIOUS  FEVERS. 


669 


most  often  in  the  breast.  There  may  frequently  be  found,  in 
women  of  sensitive  nervous  organism,  a  well-marked  fever,  which 
can  be  traced  to  no  other  cause  than  engorgement  and  distention 
of  the  mammary  gland.  There  is  usually  a  history  of  exposure 
to  colds  or  drafts  of  air  in  nursing  the  child.  For  twenty-four 
hours  afterward  there  may  be  high  fever  and  every  evidence  of 
acute  illness.  Hot  fomentations  on  the  breast,  evacuation,  support 
of  the  gland,  and  a  saline  purge  dissipate  the  symptoms  in  twenty- 
four  hours.  The  appended  temperature-chart  (Fig.  520)  illustrates 
the  influence  of  mammary  congestion  upon  the  temperature. 

The  focus  of  irritation  may  be  anywhere  in  the  body. 
A  primipara  was  delivered  under  my  care  without  difficulty 
of  a  healthy  infant.  During  the  early  part  of  the  puer- 
peral state  she  complained  of  a  constant  and  distressing  head- 
ache ;  diarrhea  appeared,  which  resisted  treatment,  and  the 
woman's  mental  state  tended  rapidly  toward  pronounced  melan- 
cholia. There  was  fever,  apparently  of  a  septic  character.  On 
the  ninth  day  a  tape-worm  fourteen  and   one-half  feet  long  was 


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^ 

Fig.  522. — Rise  of  temperature  following  perforation  of  the  uterus. 

passed  from  the  bowel,  and  shortly  afterward    the  temperature 
became  normal. 

The  great  elevation  of  temperature  which  often  follows  per- 
foration of  the  uterus  into  the  peritoneal  cavity,  appearing,  as  it 
commonly  does,  immediately,  should  also  be  attributed  more  to 
an  intense  reflex  irritation  than  to  sejiticemia.  The  chart,  flgure 
522,  is  from  a  case  in  which  the  jjlacenla  was  abnormally  adhe- 
rent. Separation  was  accomplished  four  hours  after  delivery  by 
means  of  the  fingers  and  a  curet.  Ulceration  of  a  limited  area 
in  the  placental  site  followed,  which  ended  in  perforation  and 
death    on   the    third   day.     High  fever  occasionally  appears  in 


670 


PATHOLOGY  OF   THE   PUERPERIUM. 


consequence  of  an  acute  retrodisplacement  of  the  puerperal 
uterus,  sometimes  as  late  as  the  fourth  week.  If  the  rise  of 
temperature  is  simply  due  to  irritation,  it  subsides  within  a  few 
hours  after  the  uterus  is  replaced. 

Fever  in  the  Puerperal  State  from  Cerebral  Disease.— 
A  puerpera  might  have  a  tumor  in  the  brain  or  spinal  cord,  in- 
sular sclerosis,  locomotor  ataxia,  or  degenerative  changes  in  the 
brain — all  of  which  could  give  rise  to  elevations  of  temperature.  ^ 
It  is,  however,  to  cerebral  hemorrhages  and  embolism  that  one 
should  usually  look  for  an  explanation  of  fever  arising  from  brain 
disease,  for  these  accidents  are  by  no  means  rare  in  the  puerperal 
state  ;  and  if  the  hemorrhage  or  embolism  affects  certain  regions, 
a  rise  of  temperature,  often  to  a  great  height,  is  almost  sure  to 


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Fig.    523. — Fever-chart  af  patient  who  died  of  eclampsia. 


follow.     A  temperature  of  108°  in  the  axilla  has  been  noted  in  a 
case  of  cerebral  embolism  following  child-birth.^ 

Fever  with  Eclampsia. — It  is  justifiable  to  put  the  fever  of 
eclampsia  among  the  non-infectious  fevers  of  the  puerperal  state. 
Winckel,^  writing  in  1878,  said  he  had  observed  and  had 
called  attention  to  the  fever  accompanying  eclampsia  fifteen  years 
before;  he  was  accordingly  the  first  to  refer  to  it.  Bourneville 
and  Budin  pubHshed  this  fact  as  an  original  discovery  in  1872. 

^  W.  Hale  White,  "The  Theory  of  a  Ileat-center,  from  a  Clinical  Point  of 
View,"  "Guy's  Hospital  Reports,"  1SS4,  p.  49. 

'■^  Neve,  "A  Case  of  Cerebral  Embolism  with  Hyperpyrexia  following  Child- 
birth," "Lancet,"  1884,  ii,  p.  103. 

^  "Path.  u.  Therap.  des  Wochenbettes,"  3.  Aufl.,  1878,  S.  493. 


NON-INFECTIOUS  FEVERS. 


671 


With  each  con^'ulsion  there  is  a  notable  rise  of  temperature, 
until,  finally,  the  fever  may  run  very  high. 

Insolation. — Sun-stroke,  or  heat-stroke,  is  by  no  means  an 
impossible  accident  to  lying-in  women  in  the  torrid  tempera- 
ture of  the  American  summer.  The  only  case,  however,  that 
I  know  of  occurred  at  sea  in  a  ship  sailing  from  France  to 
New  Orleans.^  The  cabin  in  which  the  woman  was  confined 
was  hot  and  ill-ventilated.  The  temperature  of  the  air  was 
93.4°  F.  A  portion  of  the  membranes  was  left  behind,  and 
the  discharge  was  offensive,  but  there  was  no  fever.  On  the 
fourth  day,  however,  the  temperature  rose   to  104°,  and   shortly 


Hg.    524. — Temperature-chart  of  syphilitic  fever. 


after  mounted  to  109.4°  in  the  rectum, 
recovered. 

Syphilitic  Fever. — In  my  experience 
child-bed,  the  disease  has  complicated 
by  the  retention  within  the  uterus  of  the 
membrane,-  which  is  so  often  seen  as 
adherent  placenta,  by  the  development 
by  septic  infection.  It  is  claimed,  howev 
syphilitic  fever  without  wound  infection. 

1  Skinner,  "  Sur  un  Cas  d' Ilyperthermie  post-puc'ri>erale,''  "  Le  Progr^s  niedi- 
cale,"  1887,  p.  269. 

^  See  Kaltenbach  on  "  Svpliihtic  Endometritis  in  Pregnancy  and  tlie  Puerperal 
State,"  "  Zeitschr.  f.  Cleburtsli.,"  Bd.  ii,  S.  225. 


The  woman  ultimately 

with  syphilitic  women  in 
puerperal  convalescence 
hypertrophied  deciduous 
a  result  of  syphilis,  by 
of  ])clvic  exudates,  and 
er,  that  there  is  a  specific 


6/2 


PATHOLOGY  OF   THE   PUERPERIUM. 


Persistence  or  Exacerbation  of  Febrile  Affections  in  the 
Puerperal  State. — A  woman  may  acquire  any  of  the  acute 
or  chronic  fevers  during  pregnancy,  which  may  persist  in  the 
puerperal  state  or  take  on  new  activity  during  that  period. 
This  is  true  of  all  the  infectious  diseases,  but  particularly  so 
of  phthisis.  The  effect  of  labor  upon  the  course  of  phthisis 
has  interested  many  observers.  It  has  been  asserted  that  the 
disease  makes  no  progress,  or,  at  least,  is  very  much  retarded 
in  the  puerperal  state.  There  is  a  fictitious  appearance  of 
regained  health  in  the  woman  by  reason  of  the  accumulation 
of  fat  to  which  pregnancy  disposes.      The  lait}^,  therefore,  enter- 


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Fig.    525. — Fever-chart   of    woman   with   advanced  phtliisis  in  pregnancy  and   the 

puerperal  state. 


tain  the  idea  that  it  is  an  advantage  for  the  phthisical  woman 
to  become  pregnant.  Xo  mistake  could  be  more  unfortunate. 
The  drain  and  strain  of  the  child-bearing  processes  are  often 
accountable  for  the  origin  of  phthisis  in  a  woman  disposed 
to  tuberculosis,  and,  if  the  disease  already  exists,  there  is  after 
delivery  an  exacerbation  of  the  fever,  an  aggravation  of  the 
pulmonary  symptoms,  and  a  rapid  loss  of  strength  and  vitality, 
which  shortens  the  patient's  life  by  many  months.  It  is  the 
duty  of  a  physician  to  advise  the  tuberculous  subject  against 
marriage  or  maternity. 

Acute  Intercurrent  Affections  in  the  Puerperal  State. — 
Any  one  of  the  acute  diseases  may  fasten  itself  upon  a  woman  after 
confinement.  They  acquire  a  special  interest  in  this  condition,  for 
their  course  is  often  modified,  the  prognosis  is  commonly  graver, 
and  the  diagnosis  is  more  difficult.  It  is  often  difficult  and 
occasionally  impossible  to  distinguish  certain  diseases — as  er}-sip- 
elas,  diphtheria,  malaria,  scarlet  fever,  and  typhoid  fever,  occurring 
during  the  lying-in  period — from  septic  infection. 

Pneumonia. — Pregnancy  and  the  puerperal  state  are  grave  com- 
plications of  the  disease.     They  increase  the  gravity  of  the  symp- 


INTERCURRENT  DISEASES.  673 

toms  and  make  the  prognosis  unfavorable.  Pneumonia  more 
frequently  attacks  a  woman  during  the  nine  months  of  pregnancy 
than  during  the  six  weeks  of  the  puerperal  state,  but  the  pneumonia 
of  pregnancy  often  becomes  a  complication  of  the  puerperium, 
for  it  frequently  induces  a  premature  expulsion  of  the  ovum  at 
the  height  of  the  attack,  and  convalescence  or  death  occurs  in  the 
lying-in  period.  In  43  cases  of  pneumonia  in  pregnancy  collected 
by  Ricau,^  there  was  premature  expulsion  of  the  fetus  in  21.  From 
these  statistics  it  further  appears  that  the  likelihood  of  the  accident 
is  increased  after  the  sixth  month.  In  28  of  the  43  observations  the 
women  had  not  passed  the  sixth  month  of  pregnancy;  of 
this  number  11  aborted.  Of  the  other  15  cases,  in  which 
the  pregnancy  was  past  six  months,  there  was  premature  labor 
in  10  instances. 

The  prognosis  of  pneumonia  in  pregnant  women  is  grave. 
Of  Ricau's  43  cases,  12  died:  5  before  the  sixth  month;  7 
after  it.  The  infants  were  expelled  in  21  cases  prematurely; 
and  of  those  which  had  reached  sufficient  development  to  exist 
outside  the  uterus  the  majority  died.  Tarnier  ^  sums  up  the 
outlook  for  mother  and  child  in  the  following  way  :  The  more 
advanced  the  pregnancy.the  greater  the  probability  of  an  expul- 
sion of  the  fetus,  the  graver  the  prognosis  for  mother  and  child. 

Treatment. — A  discussion  of  the  medical  treatment  of  pneu- 
monia has  no  place  here.  A  consideration  of  the  obstetrical 
treatment  of  the  disease  when  it  attacks  the  pregnant  woman 
is  important  and  is  best  handled  by  the  obstetrician.  The  ques- 
tion to  be  decided  by  him  is  whether  he  will  induce  labor 
or  avoid  interference.  Pregnancy  complicates  pneumonia  by 
mechanically  increasing  the  difficulty  of  respiration,  by  calling 
upon  the  heart  for  extra  work,  and  by  demanding  unusual 
facilities  for  disposing  of  the  waste-products  of  two  organisms, 
part  of  which  should  be  discharged  through  the  lungs.  It 
would  seem,  therefore,  that  the  uterine  cavity  should  be  emptied 
for  the  mother's  sake,  more  especially  as  the  infant  deserves 
but  small  consideration,  being  almost  certainly  doomed.  But 
the  evacuation  of  the  uterus,  the  contraction  of  its  walls,  and 
great  diminution  of  its  blood-supply  favor  a  determination  of 
blood  to  other  internal  organs,  among  them  the  lungs.  The 
exhausting  discharges  of  the  puerperal  state,  moreover,  may 
fatally  waste  the  patient's  strength,  while  in  her  feeble  and 
unresisting  condition  it  is  possible  at  least  to  have  a  general 
septic  infection  added  to  the  pulmonary  disease.  Statistics  cer- 
tainly do   not  speak   in   favor  of  artificially  inducing  abortion  or 

i"Th6se  de  Paris, "  1874. 

2  Tarnier  et  Budin,  "  Traile  de  I'Art  des  Accouchements,"  t.  ii,  Paris,  1886. 
43 


6/4  PATHOLOGY  OF   THE   PUERPERIUM. 

premature  labor.  Matton  ^  says  that  of  i8  cases  in  which  preg- 
nancy was  interrupted  9  woman  died,  while  in  20  women  who 
suffered  from  pneumonia  without  abortion  but  i  succumbed. 
Chatelain's^  statistics  include  39  cases;  in  10,  abortion  occurred; 
in  9,  premature  labor  was  induced.  Of  the  19,  10  died,  and  of  the 
remaining  20,  10  also  died,  showing  that  little  was  gained  by  the 
interruption  of  pregnancy. 

Pleurisy  may  possibly  complicate  the  puerperal  state.  It 
is  simply  an  intercurrent  affection,  to  be  treated  on  general  prin- 
ciples. It  does  not  influence  the  course  of  pregnancy,  nor  is  it 
influenced  by  the  woman's  condition. 

The  Exanthemata. — Scarlet  Fever. — Although  this  disease 
in  the  puerperal  state  has  attracted  much  attention  and  aroused 
extended  discussion  among  medical  Avriters,  there  are  still  several 
points  in  its  relationship  with  the  puerperium  in  dispute.  It  is 
not  strange  that  there  should  be  some  confusion  and  difference 
of  opinion  in  regard  to  scarlet  fever  in  the  puerpera,  for  its  course 
is  often  much  modified  by  the  woman's  condition  ;  it  may  be 
compHcated  by  the  coexistence  of  septic  infection;  there  may  be, 
on  the  other  hand,  scarlatiniform  rashes  in  the  course  of  septi- 
cemia, although  scarlatina  is  excluded;  and,  moreover,  there 
may  be,  in  certain  cases,  after  infection  with  scarlatina,  pelvic 
symptoms  indistinguishable  from  those  of  an  infected  birth-canal. 

Frequency. — Scarlet  fever  is  a  rare  complication  of  the  puerperal 
state.  Prior  to  1876  Olshausen^  collected  134  cases;  Winckel* 
saw  one  in  Rostock  ;  single  cases  are  likewise  reported  by  Pal- 
mer,^ Parvin,**  Busby,'  Harvey,^  Cummins,^  and  the  author. 
Braxton-Hicks  ^"^  asserts  that  he  has  met  with  37  cases  (!),  chiefly 
in  consulting  practice.  Epidemics  of  scarlet  fever  among  puer- 
perae  are  described  by  Boxall"  and  Meyer,^-  in  which,  respec- 
tively, 16  and  18  women  were  attacked  by  the  disease.  In  the 
discussion  on  Boxall's  paper,  several  members  of  the  London 
Obstetrical  Society  related  individual  experiences  with  the  dis- 
ease.    It  cannot  be   asserted   that  puerperas  are  peculiarly  dis- 

1  Jour,  de  Med.  de  Bruxelles,"  1872,  p.  412^ 

2  Ibid.,  1870,  t.  1,  pp.  430,  516,  and  t.  li,  p.  II. 

3  "Archiv  f.  Gyn.,"  Bd.  ix,  S.  169. 

*  "Path.  u.  Therap.  des  Wochenbettes,"  1878,  p.  529. 

5  "  Cincinnati  Lancet-Clinic,"  1887,  ix,  481. 

6  "Amer.  Jour.  Med.  Sci.,"  1884,  179.  '  Ibid.,  1887,  p.  394. 

8  "Scarlet  Fever  and  the  Puerperal  State,"  "  N.  Y.  Med.  Record,"  18S6,  xxx, 
376.  9  British  Med.  Jour.,"  1884,  i,  760. 

1"  "London  Obst.  Trans.,"  vol.  xii,  pp.  44-I13. 

11  Abstract  from  "London  Obst.  Trans."  in  "Amer.  Jour,  of  Obstetrics,"  1S88, 
PP-  547,  553,  666. 

1^  "  Ueber  Schavlach  bei  Wochnerinnen,"  "  Zeit.  f.  Geburlsh.,"  Bd.  xiv,  S.  2S9. 


INTERCURRENT  DISEASES.  675 

posed  to  scarlet  fever.  Epidemics  occur,  it  is  true,  in  lying-in 
hospitals  at  long  intervals,  but  the  proportion  of  patients  at- 
tacked is  never  very  large.  During  the  epidemic  in  the  Ma- 
ternity Hospital  of  Copenhagen,  described  by  Meyer,  only  about 
one  per  cent,  of  the  lying-in  patients  acquired  the  disease.  Box- 
all  says  that  40  women  were  exposed  to  the  contagion  of  scarlet 
fever  during  an  epidemic,  without  the  slightest  detriment  to  their 
health.  During  the  years  1871-85  there  were  only  2  cases  of 
scarlet  fever,  in  the  lying-in  period,  among  the  patients  in  the 
Copenhagen  Maternity;  in  six  years  but  3  cases  of  the  kind  were 
seen  in  the  hospital  for  infectious  diseases  (Meyer).  In  twenty 
years'  hospital  service  in  the  Philadelphia,  Maternity,  and  Uni- 
versity Hospitals,  I  have  seen  but  2  cases  of  true  scarlet  fever  in 
the  puerperium. 

Infection  and  Inaibation. — Women  after  child-birth  may  be 
infected  with  scarlet  fever  in  the  ordinary  manner — through  the 
throat — or  through  wounds  in  the  genitalia.  The  latter  state- 
ment has  been  disputed,  but  the  short  period  of  incubation,  the 
fact  that  the  rash  often  begins  at  the  vulva  and  spreads  thence 
over  the  trunk,  the  common  occurrence  of  pelvic  inflammations, 
and  the  fact  that  the  diphtheric  patches  usually  seen  in  the  throat 
of  scarlet  fever,  patients  are  met  with  commonly  in  the  vagina  when 
the  disease  attacks  a  lying-in  woman,  while  the  throat  is  affected 
to  a  minor  degree  or  entirely  spared — all  indicate  the  genitalia 
as  the  point  of  entrance  for  the  specific  infection.  It  is  likely  that 
the  majority  of  women  affected  during  the  puerperium  are  infected 
by  actual  contact  with  the  disease  germs  on  fingers  or  instruments 
inserted  into  the  vagina;  but  it  is  quite  possible  that  the  poison  of 
the  disease  may  be  drawn  into  the  throat  from  the  atmosphere 
or  may  be  conveyed  to  the  genitalia  by  the  same  medium.  Before 
the  adoption  of  antiseptic  measures  in  surgical  practice  it  was  well 
understood  that  the  poison  of  scarlet  fever  might  find  entrance 
to  the  body  through  a  solution  of  continuity  in  the  skin  and  mucous 
membranes.  Paget  long  ago  pointed  out  that  the  wounded  are 
more  susceptible  to  scarlatina.^  The  woman  after  child-birth 
is  always  a  wounded  person,  and  she  is,  therefore,  more  susceptible 
to  attacks  of  the  disease.  This  puerperal  susceptibility  explains 
the  cases  which,  exposed  to  the  contagion  during  pregnancy, 
only  manifest  the  symptoms  of  the  disease  after  labor,  the  poison 
lying  dormant  for  varying  lengths  of  time  until  its  invasion  of 
the  body  is  facilitated  by  the  wounds  and  abrasions  which  always 
attend  ])arturition  ((31shausen).  This  mode  of  entrance  would  also 
explain  the  short  period  of  incubation  when  scarlet  fever  attacks 
a  puerpera.      Ordinarily,  five  to  seven   days  intervene  between 

1  See  also  Iloffa,  Volkmann's  "  Sanuiil.  kliii.  Vortrage,"  No.  292. 


6/6  PATHOLOGY   OF   THE   PUERPERIUM. 

the  date  of  infection  and  the  appearance  of  the  first  general 
symptoms.  In  the  puerperal  state,  however,  the  time  of  incu- 
bation is  shortened  to  twenty-four  or  forty-eight  hours  (Senn, 
Hervieux,  Olshausen).  In  one  of  my  cases  the  patient,  two 
weeks  before  her  confinement,  had  handled  some  old  linen  that 
had  been  used  in  a  fatal  case  of  scarlatina  ten  years  before.  She 
developed  a  violent  and  typical  attack  of  scarlet  fever  forty-eight 
hours  after  her  deliver}^ 

Olshausen  ^  says  that  four-fifths  of  all  puerperse  attacked  will 
manifest  the  first  symptoms  at  some  time  in  the  fi.rst  three  days 
after  labor ;  and  this  assertion  has  been  supported  by  the  major- 
ity of  the  cases  reported  since  the  appearance  of  his  article. 

Symptoms  and  Diagnosis. — A  frank  case  of  scarlet  fever  in 
the  puerperal  state  is  as  easily  recognizable  as  it  is  under 
any  other  circumstances  in  the  adult  male  or  female.  But 
"  in  rare  instances  the  disease  may  assume  a  masked  form 
in  which  the  ordinary  signs  of  scarlatina  are  absent,  or  so  slight 
and  evanescent  as  to  escape  observation,"  and  "in  some  such 
cases  the  only  manifestation  of  the  illness  may  be  found  in 
signs  usually  referred  to  septic  poisoning  "  (Boxall).^  It  is,  more- 
over, a  well-recognized  fact  that  one  of  the  manifestations  or 
accompaniments  of  septicemia  in  occasional  cases  is  the  appear- 
ance of  a  scarlatiniform  rash.  And,  again,  there  are  reported, 
from  time  to  time,  er}'thematous  eruptions  in  the  puerperal  state 
resembling,  on  the  one  hand,  the  rash  of  scarlet  fever,  and,  on  the 
other,  the  eruption  sometimes  associated  with  general  sepsis,^  and 
yet  apparently  unconnected  with  either  of  these  diseases.  Finally, 
there  may  coexist  in  the  same  individual  local  inflammations  about 
the  pelvic  organs  of  septic  origin  and  a  general  infection  of  the 
whole  organism  with  the  poison  of  scarlet  fever,  as  the  puerpera 
with  scarlet  fever  is  more  prone  to  streptococcic  infection  than  any 
other  patient.*  It  is  obvious,  therefore,  that  a  definite  diagnosis 
of  scarlet  fever  in  the  puerperal  state  may  be  difficult  or  even  im- 
possible. The  diffuse  nature  of  the  rash,  followed  by  desquama- 
tion; the  characteristic  appearance  of  the  tongue;  the  affection  of 
the  throat;  the  more  exaggerated  diphtheroid  inflammation  of  the 
vagina;  the  exposure  to  the  contagion  of  the  disease;  the  occurrence 

1  Loc.  cit. 

^  Braxton-Hicks  takes  an  extreme  position  in  this  connection.  He  says  that 
among  sixty-eight  cases  of  puerperal  diseases  in  his  practice  for  which  there  was  a 
demonstrable  cause,  thirty-seven  were  due  to  scarlet  fever.  This  is  an  overestimate, 
and  it  has  not  met  with  general  acceptance.  Even  Boxall's  moderate  statement  has  a 
long  list  of  names  arrayed  in  opposition  to  it,  but,  to  the  writer's  mind,  the  weight  of 
evidence  is  distinctly  in  favor  of  his  view. 

3  This  word  is  used,  in  default  of  a  better,  to  designate  infection  by  the  com- 
moner pyogenic  micro-organisms. 

*  T.  Meyer,  "  Med.  Klinik,"   1905,  Bd.  I,  No.  32,  p.  800. 


INTERCURRENT  DISEASES.  67"/ 

of  scarlatinous  nephritis;  finally,  the  infection  of  those  who  come 
in  contact  with  the  patient  and  the  subsequent  outbreak  in  them 
of  a  typical  case  of  the  disease/  make  the  diagnosis  certain.  But 
there  are  cases  in  which  the  existence  of  the  disease,  with  symptoms 
closely  resembling  sepsis,  is  overlooked,  or,  if  suspected,  is  only- 
inferred. 

The  Pcadiarities  of  Scarlet  Fever  in  the  Puerperal  State. — 
Olshausen  asserts  that  scarlet  fever  is  modified  in  three  ways  when 
the  disease  appears  during  the  puerperium  ;  it  almost  always 
appears  in  the  first  three  days  after  labor  ;  the  throat  complica- 
tions are  slight ;  the  eruption  appears  quickly,  is  rapidly  diffused 
over  the  body,  and  is  apt  to  assume  a  dark-red  color.  Winckel 
states  that  convalescence  is  commonly  tedious.  A  careful  study 
of  the  published  cases  must  convince  any  one  that  scarlet  fever 
exercises  an  unfavorable  influence  upon  the  puerperal  state. 
The  milk-secretion  is  often  lessened,  if  not  suppressed  ;  there 
is  often  some  change  in  the  lochia,  denoting  probably  an 
exanthematous  endometritis  or  a  diphtheric  inflammation  of 
the  vagina.  In  a  number  of  the  cases  reported,  fetid  lochia  is 
noted;  in  some  a  "peculiar  odor"  is  described;  the  only 
change  noticed  may  be  an  increase  or  a  return  of  the  lochia 
rubra.  In  a  considerable  proportion  of  all  the  cases  the 
discharges  from  the  genitalia  are  unaffected.  In  10  of  the 
cases  reported  by  Meyer  rheumatic  complications  were  ob- 
served. In  2 1  of  the  cases  collected  by  Olshausen  there  was 
an  evanescent  tenderness  over  the  uterus.  The  occurrence  of 
pelvic  inflammation  is  reported  in  so  large  a  proportion  of  the 
entire  number  of  cases  that  the  association  can  not  be  a  mere 
coincidence.  Of  Meyer's  cases,  for  instance,  6  presented  evidence 
of  peri-  and  parametritis.  It  is  possible  that  the  specific  poison 
of  scarlet  fever  is  capable  of  causing  a  pelvic  peritonitis  or  an 
inflammation  of  the  pelvic  connective  tissue  when  it  enters  the 
body  through  the  wounds  along  the  genital  tract  or  finds  en- 
trance to  the  peritoneal  cavity  through  the  tubes.  Or,  per- 
haps, there  may  be  a  "  mixed  infection,"  as  happens  in  gonor- 
rhea. Whatever  the  explanation,  it  is  highly  probable  that 
pelvic  inflammation  may  occur  as  a  consequence  of  scarlatinous 
infection  during  or  after  labor.  Diarrhea  may  develop  early  in 
the  attack.  It  is  an  unfavorable  sign.  Of  21  women  in 
Olshausen's  series  thus  affected,  i  5  died. 

Prognosis. — If  the  attack  is  a  frank  one ;  if  the  genitalia  are 
not  much  involved  ;  if  the  pelvic  tissues  are  not  extensively  in- 
flamed, the  woman  will  probably  recover.  It  would  scarcely  be 
correct,  however,  to  assert  that  the  prognosis  of  scarlet  fever  in 
^  See  the  cases  reported  by  I'almer  and  Harvey,  loc.  cit. 


6/8  PATHOLOGY  OF   THE   PUERPERIUM. 

the  puerperal  state  is  favorable.  The  death-rate  among  01s- 
hausen's  cases  was  48  per  cent.  ;  of  those  infected  immediately- 
after  labor,  75  per  cent.  Of  Meyer's  18  cases,  i  died.  The  3 
cases  observed  by  Martin  all  died.  Of  Braxton-Hicks'  37 
patients,  27  died.  Many  of  these,  however,  were  not  cases  of 
scarlet  fever,  but  were  probably  cases  of  puerperal  infection  with 
a  septic  er}^thema.  Galabin  ^  twice  saw  fatal  peritonitis  during 
desquamation.  On  the  other  hand,  Hervieux  had  7  cases  which 
ended  favorably.  All  of  Boxall's  cases  recovered.  Legendre  ^ 
reports  23  cases  without  a  death.  The  single  examples  reported 
by  Palmer,  Parvin,  Busey,  Harvey,  and  Cummins  all  ended  in 
recovery.      The  two  patients  under  my  observation  recovered. 

In  scarlet  fever,  as  in  all  the  contagious  diseases  of  the  puer- 
perium,  the  patient  must  be  isolated  and  should  not  be  allowed 
to  nurse  her  child. 

Erythematous  Rashes  in  the  Puerperal  State. — A  rash  some- 
what resembling  the  exanthem  of  scarlet  fever  sometimes  makes 
its  appearance  on  the  skin  of  a  puerpera,  but  a  distinction 
can  usually  be  made  between  the  two.  In  the  simple  erythema 
there  is  apt  to  be  a  moderate  and  evanescent  fever,^  the  pulse  is 
rapid,  and  in  most  cases  fetid  lochia  is  noted,*  with  some  uterine 
or  pelvic  tenderness  ;  there  is  often  intense  itching  and  usually 
desquamation  ;  miliaria  often  make  their  appearance,  especially 
on  the  abdomen  under  the  binder,  and  there  may  be  desqua- 
mation. The  eruption  is  very  likely  the  expression  of  a  sep- 
tic infection,  usually  of  a  mild  degree ;  but  occasionally  ery- 
thema may  be  associated  with  the  gravest  forms  of  septicemia. 
Mackness  explains  the  eruption  by  the  supposition  that  some 
septic  products  are  evacuated  through  the  sweat-glands,  irritat- 
ing the  skin  and  producing  a  general  hyperemia.  His  theory  is 
supported  by  the  fact  that  the  rash  is  at  first  punctate,  seeming 
to  begin  usually  at  the  hair-bulbs,  and  soon  after  becoming 
diffuse.  The  belief  in  the  septic  nature  of  the  eruption  is  shared 
by  Winckel,  Kaposi,  Maygrier,  Geneix,  Farre,  and  many  others. 
The  superficial  resemblance  that  this  affection  bears  to  scarlet 
fever  has  led  many  observers  into  error.  Raymond''  would 
have  one  believe  that  the  eruption  is  the  manifestation  of  an 
attenuated  form  of  scarlet  fever.  With  the  same  idea  in  mind 
Gueniot   calls    the   rash  scarlatinoid.       It  is    likely  that    future 

^  Discussion  on  Boxall's  paper,  loc.  cit.  ^  See  Parvin,  loc  cit. 

"Mackness,  "Some  Scarlatinous  Rashes  Occurring  During  the  Puerperium," 
"  Edinb.  Med.  Jour.,"  August,  i88S. 

*  Mackness,  /(?i-.  cil.;  MacDonald,  "Edinb.  Obst.  See.  Trans.,"  1884-85,  x, 
235;  Charpentier ;  Gueniot,  "These,"  1862;  Poupon,  "  Eiytheme  scarlatiniform 
chez  une  Femme  recemment  accouchee,"  "La  France  medicale,"  1S84,  i,  41. 

5  "  These  d' Aggregation." 


INTERCURRENT  DISEASES.  679 

investigation  will  confirm  an  opinion,  already  expressed,  that  there 
is  an  "  infectious  erythema  "  dependent  upon  the  invasion  of  the 
body  by  a  specific  microbe,  which,  it  is  claimed,  has  been  iso- 
lated.^ 

Loviot "  has  reported  an  erythema  recurring  a  number  of  times 
during  a  year  after  an  attack  of  puerperal  sepsis.  Lipinsky^  also 
reports  two  cases  of  recurrent  erythema  in  the  puerperium.  Gaer- 
tig  *  reports  an  erythema  recurring  after  three  successive  labors, 
twice  with  fever,  the  third  time  without. 

Measles. — Pregnant  women  are  rarely  attacked  by  measles. 
The  disease  is  even  more  rare  in  the  puerperal  state,  owing  to 
the  shorter  duration  of  the  period.  The  measles  of  pregnancy, 
however,  usually  becomes  a  complication  of  the  puerperium  by 
inducing  an  expulsion  of  the  ovum.  Nine  out  of  eleven  cases 
of  measles  during  pregnancy  reported  by  Klotz^  caused  a  pre- 
mature expulsion  of  the  fetus.  Occasionally,  the  disease  first 
manifests  itself  in  the  puerperal  state.  Tarnier^  describes  an 
instance  in  his  own  experience.  Measles  in  the  child-bearing 
woman  is  a  dangerous  disease.  There  is  a  disposition  to 
hemorrhage,  and  pneumonia  is  a  frequent  and  a  very  dangerous 
complication.^ 

SmalUpox. — Pregnancy  and  the  puerperium  increase  the 
gravity  of  all  the  eruptive  fevers.  This  is  true  of  small-pox 
as  of  the  rest.  Luckily,  the  disease  is  a  rare  one  under  any 
circumstances  in  this  country,  and  as  a  complication  of  the 
puerperal  state  it  is  of  very  exceptional  occurrence. 

A  case  of  rotheln^  during  the  puerperal  state  has  been  re- 
ported. I  have  also  observed  one  case,  mild  in  character,  end- 
ing in  recovery. 

Erysipelas. — The  practical  identity  of  the  streptococcus  ery- 
sipelatis  and  the  streptococcus  pyogenes  explains  the  fact  that 
the  germs  of  the  disease,  when  introduced  into  wounds  along  the 
genital  canal  or  into  the  uterus,  are  capable  of  generating  a  violent 
form  of  puerperal  sepsis  without  manifesting  externally  the  rash, 
which  is  supposed  to  be  distinctive  of  erysipelas.  A  large  number 
of  cases  might  be  cited  in  which  contact  with  puerperal-fever 
patients  originated  an  attack  of  erysipelas,  or,  on  the  other  hand, 

^  Simon  et  Legrain,  "Contribution  ^  I'Etude  de  rErytheine  iiifectieux,"  "Ann. 
de  Dermatol,  et  de  Syphilog.,"  November,  1888. 

^  "Annales  de  Gyn.,"  July,  1894.  ^  "  Centralbl.  f.  Gyn.,"  1894. 

*  Ibid.,  p.  720.  5  "Archiv.  f.  Gyn.,"  YA.  xxix,  S.  448. 

6  Tarnier  et  Bmliii,  "  Path,  de  la  Grosse.sse,'  ]>.  17.  A  good  bibliography  pre- 
cedes the  chapter. 

''Two  fatal  case.s  are  reported  by  llulburt,  ''St.  Louis  Courier  of  Medicine," 
1887,  xvii,  p.  549. 

•*  Kite,  "  Boston  Med.  and  Surg.  Jour.,''  August  iS,  18S7. 


68o  PATHOLOGY  OF   THE   PUERPERIUM. 

in  which  puerperas  exposed  to  the  contagion  of  erysipelas  developed 
virulent  forms  of  puerperal  sepsis.^ 

Pneumonia  is  a  frequent  complication  of  puerperal  erysipelas. 
During  an  epidemic  that  Winckel  observed  in  1880,  six  out  of 
thirteen  puerperse  attacked  manifested  this  complication. 

In  relation  to  erysipelas,  as  to  all  the  infectious  fevers  of  the 
puerperium,  it  is  important  for  the  obstetrician  to  realize  that  if 
these  diseases  fasten  themselves  upon  the  woman  after  child-birth 
in  the  ordinary  manner, — that  is,  erysipelas  through  a  scratch  in 
the  skin,  scarlet  fever  from  the  throat  or  lungs,  and  so  on, — their 
course,  symptoms,  and  treatment  differ  little  from  the  ordinary 
manifestations  and  management  of  the  respective  diseases  in  an 
adult  female;  but  when  the  woman's  genital  canal  is  infected,  the 
history  is  different.  The  symptoms  are,  to  a  great  extent,  the  same, 
no  matter  what  the  nature  of  the  infection.  There  may  be  the 
same  endometritis,  the  same  involvement  of  the  uterine  walls,  the 
lymphatics,  the  blood-vessels,  the  connective  tissue,  the  tubes  and 
ovaries,  and  the  serous  membranes  after  infection  of  the  pelvic  or- 
gans by  any  one  of  the  numerous  pathogenic  micro-organisms. 
Winckel  has  seen,  in  all,  42  cases  of  erj'sipelas  during  preg- 
nancy and  the  puerperal  state;  36  of  them  developed  after  the 
delivery  of  the  infant;  6  occurred  during  pregnancy.  Of  the 
cases  in  pregnant  women,  not  one  had  its  origin  in  the  genitalia. 
Of  the  36  cases  in  the  puerperal  state,  28  began  in  the  genitalia, 
2  in  the  breast,  and  the  remainder  in  the  face  and  scalp.  Winckel, 
from  an  extensive  study  of  the  subject,  offers  the  following 
points  of  evidence  as  to  the  etiology  of  erysipelas  in  the  puer- 
peral state  and  its  connection  with  puerperal  sepsis: 

1.  By  far  the  most  frequent  points  of  origin — in  five-sevenths 
of  all  the  cases — for  puerperal  erysipelas  are  the  genitalia  and 
nates.  There  are  endemics  in  which  not  a  single  case  of  facial 
erysipelas  appears. 

2.  Primiparae  contract  the  disease  three  to  four  times  as  fre- 
quently as  multiparae. 

3.  Puerperae  with  wounds  upon  the  genitalia  are  particularly 
predisposed  to  the  disease. 

4.  Those  who  have  undergone  difficult  operative  deliveries 
acquire  the  disease  much  more  frequently  than  others. 

5.  The  infants  of  women  with  er^^sipelas  remain  free  from 
the  disease.  (Gusserow,  in  fourteen  cases,  saw  the  child  infected 
twice  ;   Goodell,  once.) 

6.  The  larger  the  number  of  women  diseased  in  a  puerperal- 
fever  epidemic,  the  larger  is  also  the  number  of  erysipelatous  cases. 

1  Winckel,  "  Ueber  das  puerperale  Erysipel,''  Separat  Abdruck  aus  dem  "Aer/.t- 
lichen  Intelligenz-Blatt,"  Muncheii,  18S5. 


INTERCURRENT  DISEASES.  68 1 

Frequency. — Erysipelas  in  the  puerperal  state  manifested  by 
a  cutaneous  eruption  is  very  uncommon. 

Symptoms  ami  Diagnosis. — If  the  erj^sipelas  manifests  its  ex- 
istence by  a  cutaneous  eruption,  the  symptoms  are  distinctive  and 
the  diagnosis  is  plain.  If,  on  the  contrary,  the  streptococci  in- 
vade internal  organs  and  tissues,  it  is  impossible  to  differentiate 
the  case  from  one  of  ordinary  streptococcus  infection. 

Prognosis. — If  the  case  is  one  of  frank  erysipelas,  starting 
from  the  breast  or  the  face,  the  prognosis  is  relatively  favorable. 
Among  14  cases  of  the  kind  described  by  Winckel  there  were 
onl}'  2  deaths.  Of  the  28  cases  in  which  the  erysipelas  orig- 
inated about  the  vulva  12  ended  fatally.^ 

Treatme7it. — The  treatment  of  er}^sipelas  of  regions  distant 
from  the  pelvic  organs  in  the  puerpera  differs  in  no  respect  from 
the  treatment  of  the  disease  under  any  circumstances,  except  that 
the  greatest  care  must  be  exercised  not  to  transfer  the  strepto- 
coccus infection  to  the  genitalia,  and  not  to  allow  the  child  to 
nurse  from  an  infected  breast. 

Puerperal  Diphtheria. — If  infection  occurs  in  the  throat,  the 
disease  is  an  accidental  complication  of  the  puerperal  state.  If 
the  infection  has  occurred  in  the  genitalia,  a  variety  of  puerperal 
sepsis  ensues  that  is  considered  in  another  place. 

Puerperal  Malaria. — Malaria  is  something  more  than  an 
acute  intercurrent  affection  of  the  puerperal  state,  for  in  some 
important  particulars  the  condition  of  the  woman's  organism  after 
labor  modifies  the  disease.  The  liability  to  infection  is  increased 
after  child-birth.  Bonfils  ^  has  collected  140  observations  of 
malarial  fever  in  child-bearing  women.  His  conclusions  are  as 
follows :  Malarial  fever  after  child-birth  predisposes  to  puer- 
peral hemorrhages,  which  occur  apparently  in  consequence  of 
the  disturbances  in  blood-pressure  accompanying  the  chills  and 
fever.  The  lacteal  secretion  is  suppressed  during  the  exacer- 
bation of  fever,  but  appears  again  after  the  febrile  stage  ;  it  is, 
however,  less  abundant.  Whether  or  not  the  milk  can  convey 
the  specific  poison  of  malaria  from  the  mother  to  the  nursing 
infant  is  an  undecided  question.  The  most  striking  phenom- 
enon in  the  puerperal  state  of  women  already  infected  with 
malaria  is  the  reawakening  of  malarial  manifestations,  probably 
by  reason  of  the  traumatism  and  the  physical  depression  follow- 

'  It  goes  without  saying  that  the  puerperal  state  predisposes  to  attacks  of  ery- 
sipelas by  furnishing  so  many  points  of  entrance  for  the  poison  in  the  wounds  of 
various  degrees  along  the  genital  canal.  It  would  seem,  also,  that  the  condition  of 
the  whole  organism  favored  the  occurrence  of  the  disease.  Doderlein  ("Miinch. 
med.  Wochens.,"  xxv,  1888)  reports  a  case  in  which  the  poison  lay  latent  for  a 
year  in  a  lymphatic  gland  and  broke  out  into  fresh  activity  after  an  abortion. 

■^  "  Pakidisme  et  I'uerperalite,"  "  Ann.  dc  Gynec.,'  1886,  xxvi,  125. 


682 


PATHOLOGY  OF   THE   PUERPERIUM. 


ing  child-birth.  The  third  day  after  labor  seems  to  be  the  usual 
time  for  the  reappearance  of  the  disease,  probably  because  of  the 
slight  elevation  of  temperature  and  of  the  general  excitement  of 
the  organism  which  accompanies  the  estabhshment  of  lactation. 

In  my  experience  the  fever  is  at  first  usually  continuous.  As 
the  patient  is  brought  under  the  influence  of  quinin  the  fever 
becomes  intermittent  and  finally  disappears  (Fig.  526).  The 
puerperal  state  predisposes  to  grave  forms  of  malarial  intoxi- 
cation. 

The  disease  may  pursue  the  mildest  possible  course,  with 
very  slight  and  irregular  fever,  which  is  easily  controlled  by 
quinin  in  small  doses.  On  the  other  hand,  the  worst  example 
of  malarial  infection  which  I  have  ever  seen  occurred  in  the  last 


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Fig.    526. — Malaria    in   the   puerperium  yielding   to   quinin   when   intra-uterine  dis- 
infection had  failed. 


month  of  pregnancy.  During  the  previous  eight  months  the 
patient  had  had  two  attacks  of  malarial  fever.  Within  a  week 
or  two  of  term,  the  disease  reappeared  in  a  grave  form.  There 
were  congestive  chills,  a  temperature  running  above  104°,  and 
finally  coma.  The  fever  was  almost  continuous.  In  the  midst 
of  the  attack  labor  came  on,  and  after  some  difiiculty  the  child 
was  extracted  by  the  breech.  After  deHvery  the  woman  grew 
worse,  and  death  seemed  inevitable,  but  by  the  daily  administra- 
tion of  seventy  to  eighty  grains  of  quinin  for  several  days,  the 
fever  was  conquered  and  the  patient  made  a  rapid  recovery. 

Diagnosis. — ^The  microscopic  examination  of  the  blood  should 
clear  up  a  doubtful  case.  The  whole  subject  of  malarial  fever 
in  the  puerperal  state  has  been  discredited  by  the  tendency  to 
conceal  cases  of  puerperal  infection  under  this  name.     The  prac- 


INTERCURRENT  DISEASES. 


683 


titioner  should  always  be  upon 
his  guard  in  this  respect.  While 
not  so  satisfactory  to  him,  it  is 
far  safer  to  his  patient  to  err 
in  the  opposite  direction;  to 
regard  a  doubtful  case  of  fever 
during  the  puerperium  as  of 
septic  and  not  of  malarial  ori- 
gin, unless  the  proof  in  sup- 
port of  the  latter  behef  is  con- 
vincing. 

Treatmento — In  the  major- 
ity of  cases  larger  doses  of 
quinin  are  required  than  under 
other  circumstances.  Refer- 
ence has  been  made  to  a  case 
in  which,  on  the  average,  sev- 
enty-five grains  were  adminis- 
tered in  the  twenty-four  hours 
for  several  successive  days.  In 
another  case  under  my  obser- 
vation, forty-five  grains  a  day 
were  given  for  a  long  time, 
with  success  in  controlling  the 
fever  and  with  no  ill  effect 
upon  the  patient.  Several 
times  an  attempt  was  made 
to  reduce  the  dose  to  thirty 
grains,  but  the  reduction  in 
the  quantity  of  the  drug  was 
always  followed  by  the  reap- 
pearance of  the  fever.  It  was 
at  one  time  erroneously  taught 
that  quinin  administered  to  a 
nursing  woman  had  a  disas- 
trous effect  upon  her  milk. 
Even  in  very  large  doses  it 
does  not  pass  into  the  milk. 

Rheumatism  and  Arthri= 
tis. — Arthritis  in  the  puerperal 
state  is  either  a  manifestation 
of  septic  infection,  with  a  lo- 
calization of  the  septic  inflam- 
mation in  a  joint,  or  else, 
■as    a    rheumatic    arthritis,    is 


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684 


PATHOLOGY  OF  THE   PUERPEKIUM. 


simply  an  accidental  intercurrent  affection.  The  diagnosis  be- 
tween septic  arthritis  and  simple  acute  rheumatism  is  not  always 
easy.  In  the  latter,  during  the  puerperal  state,  the  symptoms  are 
the  same  as  in  any  adult.  Inflammation  of  the  joints  following 
septic  infection,  on  the  other  hand,  presents  certain  peculiar 
signs.  The  joint  affected  is  usually  a  large  one,  very  often  the  knee; 
the  inflammation  is  not  fugacious;^   it  is  exceedingly  stubborn 


Day  of 

Sisease 

M ^  M E  M e: M ^  m'£^ M Ei  M £  M e: m"'m'e:'"e  M E. 

102"  —  -^  —  —r—:—r-r-r-T  —  ^~r^-r——r~—:—r~r-r-r  —  ^- 
jQjo A ; 

looo  :  A  ^  A  = '  •  •  A  ^  A  ^  -^  •  ^  =  ^  •  i  •  A  ■  ■  '■  ■ 

Zvi^m^mtfHkU^Lii'- 

*  f  :  J  :  T  :  2  :  QiS  :    :    ■  M  ■  t  ■■  J  -t^  ■  i- 

ftQO » • I'j     ■ 

Fig.  528. — Temperature-chart  of  a  puerpera  with  fever  and  uterine  tenderness, 
with  no  other  symptoms  of  sepsis.  Irrigation  and  curettage  of  the  uterus  had  no 
effect  upon  the  fever,  which  yielded  immediately  to  the  salicylate  of  sodium.  There 
had  been  an  attack  of  muscular  rheumatism  during  pregnancy. 


in  its  resistance  to  all  treatment ;  the  duration  is  usually  pro- 
longed, and  in  many  cases  there  follows  a  complete  ankylosis 
of  the  joint.  There  may  be  very  little  evidence  of  general 
septic  infection.  The  arthritis  may  make  its  appearance  late  in 
the  puerperal  state.  It  may  be  accompanied  by  very  moderate 
fever  of  an  irregular  type.  It  is  inore  apt  to  appear  in  women 
who  have  had  gonorrhea.  In  the  worst  cases  of  general  septic 
infection  the  joints  may  be  the  seat  of  metastatic  abscesses  as  well 
as  other  portions  of  the  body;  but  in  these  cases  the  symptoms 
pointing  to  a  general  septic  infection  are  plain. 

Prognosis. — The  average  duration  of  the  septic  arthritis  is 
about  three  months.  Recovery  is  the  rule,  but  with  an  ankylosed 
joint  (sixteen  times  out  of  twenty-three  (Tison) ).  In  scrofulous 
subjects  the  affected  joint  may  become  the  seat  of  a  tuber- 
culous inflammation. 

Treatment. — General  medication  is  of  little  use.  The  salicy- 
lates are  of  no  value.  Local  treatment,  in  the  shape  of  counter- 
irritation  (iodin,  blisters,  cauterization),  may  hasten  the  cure.  ^ 
If  the  inflammation  is  acute,  soothing  lotions  must  be  used.    The 

1  There  are,  however,  occasional  exceptions  to  this  rule. 

^  A  ring  of  iodin  painted  around  the  joint  and  equal  parts  of  mercurial  and  bel- 
ladonna ointment  as  a  plaster  directly  over  it  is  a  good  routine  treatment. 


INTERCURREXT  DISEASES.  685 

joint  at  first  should  be  immobilized,  but  later  a  cautious  employ- 
ment of  massage  and  passive  motion  ma}^  prevent  ankylosis. 

Muscular  rheiunatisni  may  complicate  the  puerperal  state.  If 
the  disease  affects  the  uterine  muscle  and  is  associated  with 
much  fever,  the  only  means,  practically,  of  distinguishing  be- 
tween this  affection  and  puerperal  infection  with  septic  inflamma- 
tion of  the  uterus  is  the  therapeutic  test — the  administration  of 
a  salicylate. 

Gonorrhea. — The  frequency  of  gonorrheal  infection  in  the 
puerperal  state  depends  upon  the  class  of  society  to  which  the 
women  belong.  In  the  lower  classes,  seen  in  dispensary  prac- 
tice, it  is  very  common.  In  the  upper  classes  it  is  decidedly  rare. 
The  proportion  of  cases  varies,  too,  in  different  localities. 
Noeggerath  and  Sanger^  report  that  among  1930  gynecologi- 
cal cases  during  a  single  year,  in  private  and  polyclinic  practice, 
230  (twelve  per  cent.)  owed  their  sufferings  to  gonorrheal  infec- 
tion. Among  398  pregnant  women,  100  had  a  purulent  discharge, 
presumably  from  gonorrhea  (twenty -six  per  cent.)  ;  forty  of  the 
children  developed  blennorrhagia.  This  estimate  is  too  high  to 
be  correct  as  an  average. 

The  differential  diagnosis  between  gonorrheal  and  other  pyo- 
genic puerperal  infections  is  made,  according  to  Sanger,  by  the 
following  signs :  The  progress  of  gonorrhea  is  slower.  It  very 
rarely  breaks  out  in  the  early  part  of  the  puerperal  state,  appearing 
first  about  six  or  seven  weeks  after  delivery.  The  most  violent 
cases  observed  by  Sanger  were  acquired  during  the  period  of 
uterine  involution.  It  is  difficult  to  draw  a  sharp  distinction  in 
all  cases  between  infection  by  gonococci  and  by  the  other  patho- 
genic micro-organisms  causing  local  inflammation  in  the  genital 
tract.  On  the  one  hand,  there  are  many  infectious  bacteria  which 
cause  a  severe  inflammation  of  the  mucous  membrane  alone  the 
whole  canal ;  and,  on  the  other  hand,  gonococci  can,  without 
doubt,  excite  inflammation  of  the  deeper  tissues,  and  are  certain, 
if  they  escape  from  the  tubes,  to  light  up  a  sharp  attack  of  peri- 
tonitis. The  diagnosis  may  be  made  with  approximate  certainty 
if  the  disease  existed  during  pregnancy,  or  if  a  careful  examina- 
tion detects  an  inflammation  of  the  urethra  and  of  the  vulvo- 
vaginal glands,  or  if  it  is  possible  to  detect  the  gonococcus.  The 
consequences  of  gonorrhea  in  the  puerperal  state  may  be  most 
serious.  There  is  often  a  mixed  infection,  gonococci  prepar- 
ing the  way  for  strc[)tococci  or  other  pathogenic  micro-organ- 
isms. The  local  inflammation,  under  any  circumstances,  may 
become  acute,  and  may  be  accompanietl  by  violent  peritonitis. 

'  "  Ueber  die  Beziehung  der  goiiorrlioischen  Infection  zu  Pueiperalerkmnkun- 
gen,"  "  Wien.  med.  Dlatler,"  1S86,  S.  902. 


686  PATHOLOGY  OF   THE   PUERPERIUM. 

There  may  be  a  rapid  accumulation  of  pus  in  the  tubes  during 
the  puerperium,  but  usually  the  pyosalpinx  develops  slowly. 

Skin  Diseases. — The  diseases  of  the  skin  which  make  their 
appearance  during  the  puerperal  state,  and  are  apparently  de- 
pendent upon  that  condition  for  their  origin,  are  often  a  manifes- 
tation of  septic  infection.  This  is  certainly  true  of  erythema. 
It  would  appear  to  be  true  also  of  cases  of  pemphigus,  which 
rarely  occur  after  delivery.  This  disease  ^  usually  breaks  out 
on  the  third  or  fourth  day  of  the  puerperal  state.  It  may.  or 
may  not  be  associated  with  some  rise  of  temperature.  In  one 
case  the  contents  of  the  blebs  had  a  distinctly  fetid  odor.  The 
duration  of  the  disease  is  protracted.  It  lasts,  on  the  average, 
ten  weeks.  The  woman's  general  condition  may  require  stimu- 
lants. The  distressing  itching  or  burning  of  the  skin  which  some- 
times accompanies  the  disease  is  relieved  by  a  weak  carbolic  acid 

solution. 

Diastasis  of  the  Abdominal  Muscles  in  the  Puerperal  State. 

— If  the  uterus  has  been  much  distended  during  pregnancy,  and 
if  the  abdominal  muscles  during  labor  have  been  called  upon 
to  exert  an  unusual  amount  of  force,  there  may  occur  a  wide 
separation  of  the  recti  muscles,  leaving  space  between  them  for 
a  hernia  of  the  abdominal  contents.  Prochowmick^  has  reported 
two  interesting  cases  of  the  kind.  There  was  suddenly  developed 
during  the  puerperium  sharp  abdominal  pain  with  nausea  and 
vomiting.  Careful  examination  excluded  puerperal  infection,  and 
detected  the  protrusion  of  coils  of  intestine  between  the  recti 
muscles.  The  hernia  w^as  easily  reduced,  and  a  recurrence  was 
prevented  by  a  compress  and  adhesive  strips.  In  both  instances 
the  symptoms  yielded  at  once  to  this  treatment.  The  accident 
is  not  likely  to  be  a  common  one  among  English-speaking  people 
and  in  countries  where  the  use  of  the  abdominal  binder  after 
labor  is  a  universal  custom.  Permanent  diastasis  of  the  muscles 
with  pendulous  belly  and  splanchnoptosis  is  treated  by  an  ab- 
dominal binder,  massage,  electricity,  and  Swedish  exercises.  If 
such  treatment  fails,  Webster's  operation  (p.  621)  is  indicated. 

Flatulent  Distention  of  the  Abdomen  (Tympanites). — 
There  occurs  occasionally  in  the  puerperal  state  an  extreme 
distention  of  the  abdomen,  due  to  the  overdistention  of  the 
intestines  with  gas.  The  cause  of  the  flatulence  is  a  partial  or 
complete  paralysis  of  the  muscular  coat  of  the  intestines 
without  peritoneal  inflammation.      A  firm  binder,  turpentine  by 

'  Croft,  "A  Case  of  Pemphigus  Recurring  after  Four  Consecutive  Labors," 
"Lancet,"  London,  18S7,  ii,  8t;8;  Wood,  "A  Case  of  Postpartum  Pemphigus," 
ibid.,  1888,  ii,  468. 

^  "  Die  Diastase  der  Bauchmuskeln  im  Wocheiibett,"  "  Archiv  f  Gyn.," 
xxvii,  419. 


DISEASES   OF  THE    URINARY  SYSTEM  687 

the  mouth,  and  asafetida  by  the  bowel  suffice  in  cases  of  mod- 
erate degree.  In  graver  cases  a  grain  of  calomel  every  half  hour 
until  six  grains  are  taken;  two  hours  after  the  last  dose  of  calomel 
a  quarter  of  a  grain  of  elaterium,  and  two  hours  later  an  enema 
of  an  ounce  of  glycerin,  a  half  oimce  of  turpentine,  a  half  ounce 
of  Epsom  salts,  and  two  ounces  of  water  with  strychnin  and  salicy- 
late of  eserin  hypodermically  are  indicated.  In  the  worst  cases  the 
only  remedy  which  affords  relief  is  a  puncture  of  the  large  intestine 
with  a  fine  trocar.  This  procedure  appears  to  be  devoid  of  danger. 
It  has  long  been  applied  in  the  treatment  of  animals,  especially 
sheep,  to  relieve  flatulent  dyspepsia.  It  has  also  been  adopted 
with  good  results  in  human  beings.^  In  one  recorded  instance 
the  bowel  was  tapped  twenty-eight  times  without  bad  result. 
Instead  of  puncturing  the  bowel,  the  abdomen  may  be  opened 
and  the  intestines  punctured  with  a  knife  and  irrigated. 

I  have  had  under  my  care  a  case  of  giant  colon  in  which  preg- 
nancy and  labor  gravely  aggravated  the  condition.  The  abdominal 
distention  became  so  extreme  that  it  was  necessary  to  m_ake  an 
artificial  anus  by  inguinal  colotomy  on  the  left  side  to  save  the 
woman's  life.  Twenty-eight  pounds  of  feces  were  washed  out  of 
the  colon.     The  patient  recovered. 

Acute  congestion  and  edema  of  hemorrhoids  in  the  puerperium 
causes  great  distress.  Immediate  relief  is  afforded  by  forcible 
dilatation  of  the  sphincter  under  anesthesia. 

Diseases  of  the  Urinary  System. — The  Urine. — The  average 
amount  of  urine  passed  in  the  first  six  days  is  11,160  grams. 
The  average  specific  gravity  is  loio.  The  quantity  passed 
upon  each  day  averages  as  follows:  The  first  day,  2025  c.c. 
(74.4  fl.  oz.);  the  second  day,  2271  c.c.  (76.5  fl.  oz.);  the  third 
day,  1735  c.c.  (58.6  fl.  oz.);  the  fourth  day,  1772  c.c.  (59.8  fl.  oz.); 
the  fifth  day,  1832  c.c.  (61.9  fl.  oz.);  and  the  sixth  day,  1949  c.c. 
(65.8  fl.  oz.).  It  is  not  at  all  rare  to  find  albumin  in  the  urine ^ 
shortly  after  delivery,  but  as  it  is  only  a  temporary  phenomenon, 
disappearing  within  forty-eight  hours,  as  a  rule  (Blot,  Ingersley, 
Lantos),  and  seems  to  exercise  no  injurious  influence  upon  the 
woman's  condition,,  it  may  be  regarded  as  practically  a  physiolog- 
ical occurrence. 

The  appearance  of  sugar  in  the  urine  after  delivery  is  also  a 
very  common  occurrence,  which  has  been  attributed  to  the  ab- 
sorption of  lactose  from  the  mammary  gland;  indeed,  one  ob- 

1  Priestley,  "  Note  on  Puncture  of  the  Abdomen  for  Extreme  Flatulent  Disten- 
tion," "  Lancet,"  London,  1887,  i,  718. 

-  Examining  the  urine  of  600  puerpera  directly  after  delivery,  Lantos  found  albu- 
minuria in  59.33  per  cent.  This  is  a  more  common  occurrence  by  one-third  in  primi- 
panie  than  in  multipara  ("  Beitrage  zur  Lehre  von  der  Eklampsie  und  Albuminurie," 
"  Archiv.  f.  Gyn.,"  Bd.  xxxii,  p.  365). 


688 


PATHOLOGY  OF   THE   PUERPERIUM. 


Fig.  529. —  Kiieniatous  hemorrhoids  in  the  puerperium. 


Fig.  530- — Transverse  colon  in  case  of  giant  colon. 


DISEASES    OF   THE    URIXARY  SYSTEM.  689 

server  declares  that  the  quantity  and  quahty  of  the  milk  may  be 
judged  by  the  amount  of  sugar  in  the  urine.^  But,  as  a  matter 
of  fact,  glycosuria  is  more  common  when  the  milk-secretion  fails 
than  when  the  supply  is  most  abundant.-  The  phosphates  and 
the  sulphates  increase  with  the  urea  and  with  the  excretion  of 
milk.^  The  appearance  of  peptones  in  the  urine  of  recently  de- 
livered women  is  quite  constant.* 

The  lochia  may  also  contain  peptones,  but  independently  of 
the  peptonuria  and  without  influencing  the  c|uantity  of  peptones 
in  the  urine.^  If  the  urine  after  labor  contains  albumin  in  con- 
siderable quantities  and  persistently,  it  is  evidence  of  trouble 
in  the  kidneys.  There  are  usually  associated  with  persistent 
albuminuria  other  symptoms  indicating  kidney  disease.  One 
of  these  is  acute  pain,  most  often  in  the  head,  but  sometimes 
referred  to  the  epigastrium  or  to  other  regions  of  the  body. 
There  may  be  edema.  There  is  found  in  the  urine  microscopical 
evidence  of  degenerative  changes  in  the  renal  epithelium.  Albu- 
minuric retinitis  is  not  a  very  uncommon  accompaniment  of 
kidney  disease  in  the  puerperium,  and  may  induce  complete 
blindness,  but  it  should  be  remembered  that  there  may  rarely 
occur  a  temporary  blindness  in  the  puerperal  state  independent 
altogether  of  kidney  disease.®  It  usually  comes  on  shortly  after 
delivery,  and  lasts  for  a  few  days.  Typical  examples  have  been 
reported  by  Brush  and  by  Konigstein.  The  latter  attributes  the 
accident  to  a  spasmodic  contraction  of  the  retinal  vessels  trace- 
able to  a  vasomotor  disturbance.  The  loss  of  vision  may  follow 
severe  hemorrhage  or  eclampsia,  may  be  associated  with  albu- 
minuria, or  may  be  the  result  of  a  septic  panophthalmitis. 
Konigstein  suggests,  as  a  treatment  for  the  temporary  blindness 
due  to  a  spasmodic  action  of  the  retinal  vessels,  the  inhalation 
of  amyl  nitrite.  The  woman's  nervous  system  exercises  a  pow- 
erful influence  on  the  composition  of  the  urine.     Cameron  ^  has 

1  Blot,  "  Comptes  Rendus,"  xliii,  p.  676. 

'^  Hofmeister,  "  Zeitschr.  f.  phys.  Chemi-e,"  Bd.  i,S.  703;  Johannovsky,  "  Arcliiv 
f.  Gyn.,"  Bd.  xii,  S.  448.  A  full  bibliography  on  this  subject  may  be  found  in  Schroe- 
der's  "  Geburtshiilfe,"  10.  Aufl.,  p.  236. 

•'  Grammatikati,  "  Ueber  die  Schwankungen  der  Stickstoffbestandtheile  des  Ilarns 
in  den  ersten  Tagen  des  Wochenbettes,"  "  Centralblatt  f.  Gyn.,"  18S4,  p.  353. 

*  Fischel,  "  Ueber  puerperale  Peptonurie,"  "  Archiv  f.  Gyn.,"  1884,  xxiv,  p.  400, 
and  "  Neue  Untersuchungen  iiber  den  Peptongehalt  der  Lochien  nebst  liemerkungen 
iiber  die  Ursachen  der  puerperalen  Peptonurie,"  ibid.,  1S85,  xxvi,  120;  Biagio,  "La 
Peptonuria  puerperale,"  "Ann.  di  Osiel.,"  1887,  ix,  202. 

^Fischel,  loc.  cit. 

^15rush,  "A  Case  of  Temporary  Blindness  following  Child-birth,  '  "  Obstet. 
Gazette,"  vii,  1884  ;  Konigstein,  "  Erblindung  nach  einer  Geburt  in  I'olge  von  Isch- 
jemia  Retinre,"  "  Wiener  nied.  Presse,"   1S85,  xxvi,  5S5. 

'"High   Temperature   and   Glycosuria   in  the   Puerjieral  State,  the  Result  of 
Nervous  Influences,"  "Montreal  Med.  Jour.,"  Jan.,  1SS9. 
44 


690  PATHOLOGY  OF   THE   PUERPERIUM. 

reported  an  extraordinary  case  of  high  temperature  and  glyco- 
suria in  the  puerperal  state,  the  result  of  nervous  influences. 
The  temperature  rose  during  waking  hours  and  fell  during  sleep, 
without  corresponding  variation  in  pulse.  The  glycosuria  seemed 
to  have  direct  connection  with  the  nervous  phenomena,  and  lasted 
only  a  short  time. 

Hematuria,  when  seen  in  the  puerperal  state,  has  almost  in- 
variably persisted  from  pregnancy.  In  these  cases  there  are  usu- 
ally bleeding  hemorrhoids  of  the  bladder,  due  to  the  mechanical 
interference  with  the  pelvic  circulation  by  the  presence  of  the 
gravid  womb.  The  blood  disappears  from  the  urine  in  a  few  days 
after  delivery.  In  bad  cases  of  septic  infection  of  the  vesical 
mucous  membrane,  as  a  result  of  injury  with  instruments,  or  as 
a  consequence  of  vesicovaginal  fistulae,  the  same  symptom  may 
appear,  but  the  differential  diagnosis  is  easy.  Renal  and  vesical 
calculi,  malignant  tumors  of  the  kidney  and  bladder  and  papillo- 
mata  of  the  latter  are  possible  causes. 

The  Kidneys. — Hervieux  divides  the  diseases  of  the  kidneys 
in  the  puerperal  state  under  four  heads :  First,  inflammatory 
nephritis  ;  second,  metastatic  nephritis  ;  third,  evanescent  albu- 
minuric nephritis  ;  and  fourth,  subacute  albuminuric  nephritis. 
In  the  first  stage  of  inflammatory  nephritis  one  finds  hyperemia 
and  tumefaction  of  the  organ.  Often  this  condition  is  associ- 
ated with  general  septicemia.  If  the  disease  develops  primarily 
in  the  puerperal  state,  it  is  probably  a  manifestation  or  an 
accompaniment  of  general  septic  infection,  and  is  often  unde- 
tected in  the  midst  of  other  complications  presenting  more  obvi- 
ous and  more  alarming  symptoms.  An  intense  hyperemia  of 
the  kidney  associated  with  septic  infection  may  result  in  an 
apoplexy.  Metastatic  nephritis  is,  of  course,  the  result  of  septic 
infection.  In  the  evanescent  albuminuric  nephritis  the  kidney  is 
increased  in  size.  Its  surface  is  smooth ;  the  fibrous  tunic, 
thickened  and  injected,  is  easily  stripped  off  This  increase  in 
size  is  due  principally  to  the  tumefaction  of  the  cortex.  In  the 
fourth  variety  of  kidney  diseases  in  the  puerperal  state  the 
course  is  more  tedious,  and  it  may  i>ass  into  chronic  nephritis. 
Maguire  asserts  that  the  lesion  most  commonly  found  in  cases  of 
puerperal  albuminuria  is  one  of  anemia  of  the  kidney  with  fatty 
degeneration.  Lantos,^  in  the  records  of  39  postmortem  exami- 
nations of  puerperae  who  had  not  died  from  eclampsia  or  neph- 
ritis, found  in  15  cases  the  kidney  described  as  "anemic,"  in 
21  "pale,"  and  only  in  3  "congested."  Among  16  women  who 
had   presented  symptoms    of  kidney  disease  there  were   found 

1  Loc.  cit. 


DISEASES   OF   THE    URINARY  SYSTEM.  69 1 

twice  acute  parenchymatous  nephritis,  once  acute  hemorrhagic 
nephritis,  nine  times  parenchymatous  degeneration,  and  four 
times  albuminoid  degeneration. 

In  rare  instances,  complete  suppression  of  urine  after  labor 
is  observed,  usually  with  a  fatal  result.  It  is  explained  by  an  acute 
exacerbation  of  an  old  nephritis.^ 

Dislocation  of  the  kidney  may  occur  in  the  puerperium  or 
during  labor.  It  may  be  twisted  on  its  pedicle  and  an  acute 
hydronephrosis  may  result.  The  kidney  is  very  much  enlarged, 
there  is  intense  pain  and  perhaps  high  fever.  Rest  in  bed  and 
the  application  of  the  ice  coil  give  relief  When  the  obstruction 
is  relieved  there  is  a  copious  discharge  of  urine. 

Incontinence  of  Urine. — There  may  be  an  involuntary  escape 
of  urine  after  labor  in  consequence  of  an  overfilled  bladder,  of 
paresis  in  the  sphincter  muscle,  and  of  a  perforation  communi- 
cating with  the  vagina  or  some  portion  of  the  genital  tract. 
The  first  cause,  the  overflow  of  retention,  should  always  be  sus- 
pected and  looked  for,  as  it  is  the  most  common.  The  treat- 
ment varies  with  the  cause  of  incontinence.  The  use  of  a 
catheter  removes  the  difficulty  in  cases  of  the  first  category.  Cases 
of  the  second  group  are  more  difficult  to  deal  with.  The  par- 
tially paralyzed  muscle,  as  a  rule,  regains  its  tone  in  a  short  time. 
It  may  be  possible  to  hasten  recovery  in  a  chronic  case  by  the 
administration  of  tonics,  the  use  of  local  astringents,  or,  perhaps, 
by  the  apphcation  of  electricity.-  The  preventive  treatment 
should  never  be  neglected.  These  cases  almost  invariably 
follow  delayed  and  difficult  labors  with  head  presentations.  A 
timely  interference,  therefore,  would  save  the  woman  the  dis- 
comfort, and  even  danger,  of  a  constant  dribbling  of  urine  over 
the  external  genitals.^  The  repair  of  the  urogenital  trigonum 
muscle,  which  acts  as  a  compressor  urethras,  often  restores  conti- 
nence. It  is  necessary  in  some  cases  after  all  other  treatment 
has  failed  to  incise  the  neck  of  the  bladder,  shorten  the  sphincter, 
join  its  ends  with  sutures,  and  to  perform  an  operation  for  cysto- 
cele  on  the  anterior  vaginal  wall.  The  author  has  cured  in- 
tractable cases  of  long  standing  in  this  manner. 

Cases  of  the  third  order  should  be  managed  by  attempting 
to  obtain  a  primary  closure  of  the  fistulous  opening.  This  can 
be  effected  in  some  cases,  if  tiie  fistula  is  not  too  large,  by  touch- 
ing its  edges  with  a  strong  caustic — nitric  acid.      If  this  trcat- 

*  Botall,  "Jour,  of  Ohst.  and  Gyn.  of  llic  IJiiiish  Einiiire,''   1902,  p.  512. 

^  The  author  has  restored  continence  by  Faradism  with  a  bipolar  urethral  elec- 
trode. 

^  Bechadergue-Lagr^ze,  "  Incontinence  d'Urine  sans  Fistule  consecutive  i 
I'Accouchement,"  " '1  hese  de  Paris,"  1886. 


692  PATHOLOGY  OF   THE   PUERPERIUM. 

ment  fails,  a  secondary  operation  for  vesico-vaginal  fistula  is  in- 
dicated. 

Diseases  of  the  Nervous  System. — For  the  psychoses  and 

the  neuroses,  see  page  254. 

Lesions  of  sacral  plexuses,  neuritis,  and  nerve  degeneration 
from  pressure  during  iabor  are  usually  seen  in  a  justominor 
pelvis  or  in  one  with  a  slight  projection  of  the  promontoiy, 
which  affords  insufficient  protection  to  the  nerve -trunks  on  either 
side  of  it.  Puerperal  paralysis  may  result.  Both  limbs  may 
suffer  (paraplegia),  or  there  may  be  unilateral  paralysis,  with 
atrophy  and  anesthesia.  The  leg  or  legs  m.ay  be  the  seat  of 
constant  pain,  and  may  be  very  hyperesthetic.  Pressure  upon 
the  sciatic  nerve  or  movement  of  the  affected  limb  may  cause 
agonizing  pain,  or  there  may  be  intense  and  persistent  pain  in 
the  pelvis,  unassociated  with  disease  of  the  sexual  organs.  Press- 
ure with  the  finger  in  the  rectum  upon  the  sacral  plexus  causes 
exquisite  suffering.  Neuritis  of  the  pelvic  nerve-trunks  may  be 
the  result  of  pressure  from  exudates  or  of  their  involvement  in 
septic  inflammations.  Fixation  and  extension  of  the  limb  give 
the  greatest  relief  at  first.  Immobilization  of  the  whole  body  in 
the  orthopedic  surgeon's  wire  cuirass  is  the  most  efficient  means 
of  securing  perfect  quiet  and  comfort.  When  the  acute  stage  has 
subsided,  massage,  electricity,  and  passive  movements  hasten  the 
restoration  of  the  limb.  The  prognosis  is  fairly  good.  There 
may  be,  after  child-birth,  neuritis  of  nerves  distant  from  the 
genital  region  (the  ulnar,  for  instance).  Multiple  neuritis  in  al- 
coholic subjects  may  develop  after  child-birth  or  during  preg- 
nancy. Laury^  makes  three  divisions  of  puerperal  neuritis — 
traumatic,  septic  inflammatory  by  extension,  and  infectious  neu- 
ritis of  distant  nerves  and  of  the  spinal  cord. 

Apoplexies  of  the  Brain  and  Spinal  Cord ;  Aphasia ;  Hemiplegia ; 
Paraplegia. — There  is  a  predisposition  to  apoplexies  in  the  central 
nervous  system  during  labor,  especially  in  women  whose  vessels 
are  diseased  in  consequence  of  insufficient  kidney-excretion. 

Ascending  Myelitis 1  have  seen  an  ascending  myelitis  first 

manifesting  itself  some  two  weeks  after  labor,  the  temperature 
having  been  previously  normal,  but  becoming  elevated  as 
paralysis  of  the  lower  limbs  appeared.  The  paralysis  was  pro- 
gressive, and  the  result  fatal.  At  the  postmortem  examination 
no  starting-point  in  a  septic  focus  or  apoplexy  could  be 
discovered.  There  were  simply  the  signs  of  inflammation  and 
degeneration.  It  is  an  interesting  inquiry  whether  this  condition 
could  have  come  from  pressure  upon  the  lumbosacral  plexus 
and  an  ascending  nerve-degeneration. 

1  "Archives  de  Tocol,"  Nov.  i,  1S93. 


ANOMALIES    OF   THE   BREAST. 


693 


Fig.  53 J- — Asymmetrical  hypertrophy  of  breasts  in  a 
woman  recently  delivered.      University  Maternity. 


Developmental     Anomalies    of    the    Breast. — Absence   of 
Mammae. — Complete  absence  of  both  breasts  is  one  of  the  rarest 
anomahes  of  development.      Marandel,    Lousier,   and    Froriep  ^ 
each   report  a  case  of 
entire  absence  of  one 
breast,  the  other  being 
well  developed.      Im- 
perfect    development 
of      the       mammary 
glands     is     common. 
It  is  sometimes  seen 
to  an  extreme  degree 
in  cases  of  infantile  or 
absent  sexual  organs. 

Hypertrophy  of  the 
mammas  is  also  rare. 
Labarraque  -  collect- 
ed twenty-six  cases, 
of  which  only  five 
were  over  twenty-six 

years  of  age.  The  breasts  are  usually  asymmetrical.  There  is 
one  case  on  record  in  which  a  single  mammary  gland  weighed 
sixty-four  pounds.  Lactation  has  been  known  to  diminish  a 
congenital  hypertrophy  of  the  breasts.  An  overgrown  mammary 
gland,  therefore,  is  not  a  contraindication  to  suckling  the  child. 

Supernumerary  Breasts — Polymastia. — Supernumerary  breasts 
and  nipples  are  more  common  than  is  generally  supposed.^  Bruce 
found  sixty  instances  in  3956  persons  examined  (1.56  per  cent,). 
Leichtenstern  places  the  frequency  at  i  in  500.  Both  observers 
declare  that  men  present  the  anomaly  about  twice  as  frequently 
as  women.  In  400  women  examined  in  one  winter  in  my  hos- 
pital services  there  was  i  case  of  polymastia.  It  is  impossible 
to  account  for  the  accessory  glands  on  the  theory  of  rever- 
sion, as  they  occur  with  no  regularity  in  situation,  but  may 
develop  at  odd  places  on  the  body.  The  most  frequent  position 
is  on  the  pectoral  surface  below  the  true  mamma  and  somewhat 
nearer  the  middle  line  ;  but  an  accessory  gland  has  been  observed 
on  the  left  shoulder  over  the  prominence  of  the  deltoid  ;  on  the 
abdominal  surface  below  the  costal  cartilages  ;  above  the  umbili- 
cus ;   in  the  axilla  ;  in  the   groin  ;  on  the  dorsal  surface  ;  on  the 


1  "Amer.  Sys.  of  Gyn.,"  vol.  ii,  338. 

"  "  Th6se  de  Paris,"  1875.  "IJiiateral  Diffuse  Virginal  Hypertrophy  of  the 
Breasts."     G.  B.  Johnston,  "  Tr.  S.  Surg,  and  G)n.  Soc,"  1903. 

^"Supernumerary  Breasts  and  NipjjJes."  E.  B.  Young,  "Boston  Med.  and 
Surg.  Journal,"  March  24,  1904. 


694 


PATHOLOGY  OF   THE   PUERPERIUM. 


labium  majus  ;  on  the  buttock,  and  on  the  outer  aspect  of  the 
left  thigh.  In  cases  reported  by  Edwards  ^  and  Handyside,  and 
in  some  others,  including  one  of  the  author's,  heredity  seems  to 
have  been  a  probable  explanation  for  the  development  of  the 
supernumerary  mamm^  ;  but  in  the  vast  majority  of  cases  no 
hereditary  influence  can  be  traced. 

Ahlfeld^   explains  the  presence  of  mamm^  on  odd  parts  of 
the  body  by  the  theory  that  portions  of  the  embr\-onal  material 


Fig.  532. — Polymastia  :  nine  breasts  and  nipples. 
Dr.  D.  E.  Kercher.) 


(Seen  in  consultation  witii 


entering  into  the  composition  of  the  mammary  gland  are  carried 
to  and  implanted  upon  any  portion  of  the  exterior  of  the  body 
by  means  of  the  amnion. 

The  woman  represented  in  figure  532  is  remarkable  for  the 
almost  unprecedented  number  of  breasts  and  nipples  that  she 
possesses.^  She  has  nine  mamm£e  all  told,  and  as  many  nipples, 
every  one  of  which  secreted  milk  profusely.  The  two  normal 
glands  are  ver}^  large.  The  nipple  of  the  gland  in  the  left 
axilla  is  not  shown  plainly  in  the  illustration  on  account  of  its 
situation,  and  it  is  not  eas}^  to  see  it  in  the  woman  herself,  con- 
cealed as  it  is  b}'  the  axillary  hair,  but  when  the  corresponding 
gland  in  the  axilla  was  compressed,  a  stream  of  milk  was  pro- 
jected several  feet  from  the  woman's  body. 

As  may  be  seen,  the  glands  are  arranged  wath  some  symme- 
try.    There  are  five  on  the  left  and  four  on  the  right  side. 

The  woman  is  a  negress,  nineteen  years  old,  and  a  I\''-para. 
Her  child  was  born  prematurely.      Her  mother  had  an  accessory 

'  "Medical  News,"  March  6,  1886  (good  bibliography).  See  also  Goldberger 
(".^rchiv  f.  Gyn.,''  xlix,  H.  2,  S.  272),  who  states  that  there  are  262  cases  recorded 
in  literature.  -  '■  Missbildungen  der  Menschen." 

^  Neugebauer  has  reported  a  case  of  polymastia  with  ten  nipples.  "  Central- 
blaltf.  Gyn.,"  1886,  No.  45. 


ANOMALIES   IN  MILK  SECRETION. 


695 


mamma   on  the  abdomen  that  secreted  milk   during  periods  of 
lactation. 

Anatomical  Anomalies  of  the  Nipple. — The  shape  of  the  nipple 
may  unfit  it  for  nursing,  predisposing  to  injury  by  the  child's  gums, 
to  fissure  and  ulcerations  fsee  Fig.  534),  or  making  it  a  mechanical 
impossibility  for  the  child  to  take  hold,  as  in  inverted  nipples  (Fig. 
534).  The  nipples  should  always  be  examined  during  preg- 
nancy. If  they  are  inverted,  a  systematic  attempt  should  be 
made  during  the  last  month  to  draw  them  out  with  a  breast- 


Fig.  533. — Supernumerary'  nipple  and  small  mammar)'  gland  upon  left  buttock.    It  was 
always  possible  during  pregnancy  to  squeeze  out  a  drop  of  milk  (author's  case). 


pump.     Should  this  attempt  fail,  a  nipple-shield  might  enable 
the  child  to  nurse. 

Abnormalities  of  the  Breasts  and  Anomalies  in  the  Milk 
Secretion. — Alilk  secretion  begins  usualh'  fort\'-eight  hours 
after  delivery.  Previous  to  this  time  a  thin  fluid  may  be  squeezed 
from  the  breast,  containing  large  cells,  within  which  are  many 
fat-globules.  To  this  substance  the  name  "colostrum"  has 
been  given,  and  the  cells  are  called  colostrum  corpuscles.  It  is 
always  difficult  to  estimate  the  exact  quantity  of  milk  secreted. 
The  best  way  is  to  draw  the  milk  with  a  breast-pump  at  regular 
intervals  during  the  twenty-four  hours  ;  but  the  breast-pump  does 
not  excite  maternal  emotion,  and,  therefore,  it  alwa}'s  draws  a  less 
quantity  than  would  be  furnished  a  suckling  infant,  for  the  breast 


696 


PATHOLOGY  OF   THE   PUERPERIUM. 


is  in  some  degree  an  erectile  organ,  and  even  the  sight  of  the 
child  may  be  sufficient  to  produce  a  flow  of  milk.  Allowing 
for  these  errors,  there  is  found,  at  the  end  of  the  seventh  day, 
about  fourteen  ounces  in  the  twenty -four  hours.  During  the  five 
preceding  days  the  quantity  is  small  and  variable.  By  the  end 
of  the  fourth  week  the  quantity  of  milk  secreted  in  the  twenty- 
four  hours  reaches  about  two  pints.  From  this  time  it  increases 
gradually  until  the  sixth  or  seventh  month,  v/hen  about  three 
pints  of  milk  can  be  drawn  from  the  breast  in  twenty-four  hours. 
After  the  eighth  month  the  quantity  of  milk  gradually  decreases. 
A  curious  anomaly  of  milk  secretion  is  its  occurrence  independent 


Fig.  534. — Faulty  development  of  the  nipple  (Dickinson) 


of  the  puerperal  state,  as  in  old  women  or  young  girls,^  after  opera- 
tions upon  the  ovaries,^  at  the  menstrual  period,^  or  as  a  vicarious 
menstruation,  in  pseudocyesis,  in  association  with  pelvic  and  ab- 
dominal tumors,  even  in  the  adult  male.*  The  most  important 
abnormalities  of  milk  secretion  may  be  grouped  under  two  main 
headings — quantitative  and  qualitative. 

Deficient  secretion  in  its  extreme  degree  is  known  as  "  agalac- 

1  Gellhorn,  "Abnormal  Secretion  from  the  Mammary  Glands  in  Non-pregnant 
Women,"  "Jour.  Am.  Med.  Assoc,"  p.  1S39,  1908. 

^  Penrose,  "  M.  and  S.  Rep.,"  1889,  326. 

'  Sinety,  "  Traite  de  Gynec,"  p.  955- 

"  "John  Hunter's  Notes,"  quoted  by  Barnes  ;  Humboldt,  "  Raise  in  die  .^qui- 
noctiale  Gegenden  des  neuen  Continents,"  Bd.  ii,  S.  40. 


ANOMALIES  IN  MILK  SECRETION.  697 

tia,"  complete  absence  of  milk,  which  is  exceedingly  rare.  Win- 
ckel,  in  an  enormous  experience,  asserts  that  he  has  never  seen  an 
example — that  there  is  always  some  little  milk  secretion,  which 
may,  however,  escape  notice  without  close  observation.  There  are 
a  few  recorded  cases  of  complete  absence  of  the  breasts.  Agalac- 
tia would  be  a  necessary  consequence.  Deficient  milk  secretion  is 
by  no  means  uncommon.  There  are  many  causes  preventing  nor- 
mal activity  in  the  mammary  gland.  Premature  maternity  may 
account  for  it.  Advanced  age  is  another  cause  assigned  for  defi- 
cient lactation.  There  is  either  atrophy  of  the  gland  or  exhaustion 
by  previous  acti\^ity.  The  nearest  approach  to  complete  agalactia 
which  I  ever  witnessed  w^as  in  a  w^oman  who  had  her  first  living 
child  at  the  age  of  forty-three.  She  had  been  married  at  forty, 
and  had  had  previously  two  children  still-born.  There  was  so 
little  milk  secretion  that  it  was  scarcely  noticeable. 

Perhaps  the  most  frequent  cause  of  insufficient  milk  secretion 
is  lack  of  development  in  the  glandular  tissue,  which  may  be 
hereditar}'-,  may  depend  upon  the  continuous  pressure  from  the 
clothing,  or  may  be  associated  with  a  defective  development  of 
the  remainder  of  the  body,  especially  of  the  genital  organs, 
Altmann  ^  has  called  attention  to  the  hereditary  form  of  atrophy 
in  the  mammary  gland.  In  parts  of  Bavaria,  where  it  has  been 
the  custom  for  centuries  to  nourish  the  children  artificially,  the 
mammary  glands  no  longer  secrete  milk.  In  Munich,  of  the 
women  who  did  not  nurse  their  infants,  fifty-eight  per  cent,  were 
said  to  be  physically  unable  to  do  so.  Of  the  women  w^ho 
nursed  their  children,  seventy  per  cent,  had  to  resort  to  mixed 
feeding.  In  other  parts  of  Germany,  on  the  contrary,  notably 
in  Silesia,  where  the  custom  of  suckling  children  has  been  care- 
fully observed  for  many  generations,  it  is  rare  to  find  mothers 
with  an  insufficient  supply  of  milk. 

The  ability  of  the  breast  to  furnish  milk  does  not  necessarily 
depend  upon  its  size,  for  a  large  mammary  gland  may  consist 
chiefly  of  connective  tissue,  while  in  another  apparently  ill-devel- 
oped the  gland-tissue  is  abundant  and  the  milk-supply  ample. 
During  pregnancy  the  glandular  structure  of  the  breasts  takes 
on  an  active  growth  and  development,  while  the  connective  tissue 
decreases  to  a  marked  degree.  If  lactation  is  not  practised, 
there  begins  at  once  an  involution  of  the  gland,  a  shrinkage  of 
the  epithelial  structures,  and  a  regrowth  of  connective  tissue.  If 
involution  is  allowed  to  occur  after  the  birth  of  the  first  child,  it 
is  more  difficult  after  subseciuent  deliveries  to  awaken  the  breast 
to  functional  activity. 

I  "  Ueher  die  Inactivitatsalrophie  der  wcihlichen  Brustdriisen,"  Virchow's 
•*  Archiv,"  Bd.  cxi,  p.  318. 


PATHOLOGY  OF  THE   PUERPERIUM. 


The  mammary  secretion,  at  first  sufficient,  may  at  times  be 
much  diminished  as  the  resuh  of  hemorrhages  or  of  diarrhea,  in 
consequence  of   an  acute  febrile   attack  during  lactation,  or  of 


Fig.  535. — Mammary  gland  of  a  nullipara  (^from  Silesia).      X  S^O- 


inflammation  within  the  gland  itself.  Serious  organic  diseases 
may  also  be  a  cause,  and  insufficient  nourishment  must  be  held 
accountable  in  some  cases.      During-  the  siege  of  Paris  an  obser- 


Fig.  536. — Mammary  gland  of  a  nullipara  (from  Silesia).      X  S^- 


vation  of  forty-three  nursing  woman  by  Decaisne  ^  proved  that 
with  imperfect  nutrition  the  total  quantity  of  the  milk  is  much 

1  "  Des  Modifications  que  subit  le  lait  de  femme  pour  suite  d'une  alimentation 
insuffisante;  observations  recueillies  pendant  la  siege  de  Paris,"  "  Comptes  Rend.," 
Ixxiii,  No.  2. 


ANOMALIES  IN  IMILK  SECRETION. 


699 


decreased.  Almost  one-third  of  these  women  lost  their  chil- 
dren by  starvation.  Emotions  exert  an  extraordinary  influence 
upon  lactation.  Those  which  are  of  gradual  development  and 
long  continuance,  as  profound  grief,  tend  to  progressively  dimin- 
ish the  amount  of  milk.  Emotions  of  sudden  onset  and  short 
duration,  as  fright  or  anger,  either  totally  stop  the  formation  of 


Fig.  537. — Mammary  gland  of  a  nullipara  (from 
Bavaria).      X  S^- 


Fig.  538- — Mammary 
gland  of  a  nullipara  (from 
Bavaria).     X  S^o. 


milk,  or  else  so  alter  its  constitution  that  it  becomes  a  rank 
poison  to  the  child.  The  return  of  menstruation  sometimes  af- 
fects the  quantity  and  quality  of  a  woman's  milk,  but  not  nearly 
so  often  as  is  popularly  supposed.  Zweifel  states  positively  that 
for  the  most  part  the  return  of  the  menses  is  without  influence 
upon  lactation.  This  statement  is  in  accord  with  the  experi- 
ence of  Winckel,  Joux,  Tilt,  Becquerel,  Vernois,  and  my  own. 
There  are  a  few  other  rarer  causes  to  which  deficient  mammary 
secretion  has  been  ascribed.  It  has  been  said  that  the  exit  of 
the  milk-ducts  may  be  obstructed  by  an  accumulation  of  epi- 
thelium recognized  by  a  minute  white,  projecting,  translucent 
vesicle  upon  the  nipple  at  the  opening  of  the  obstructed  duct. 
Nasal,  pharyngeal,  or  bronchial  catarrhs  are  suj)posed  to  dimin- 
ish the  quantity  of  milk.  The  mammary  gland  is  described  in 
some  cases  as  torpid.  A  failure  to  furnish  enough  milk  is  as- 
cribed occasionally  to  the  fact  that  the  individual  a])i)roaches  the 
male  type.  The  milk-supply  is  rarely  abundant  after  premature 
delivery  or  the  delivery  of  dead  infants.  Extreme  obesity  may 
almost  entirely  prevent  a  functional  activity  of  the  mammary 
gland. 

Treatment. — ll   is  olj\i()us  tliat   no  single  ])lan   of  treatment 
will  increase  a  deficient  milk-sup]jly.     It  is  also  apparent  that  in 


700  PATHOLOGY  OF   THE   PUERPERIUM. 

the  vast  majority  of  cases  the  cause  of  the  difficulty  is  beyond 
the  influence  of  any  treatment.  One  cannot  alter  the  age  of  the 
patient  nor  replace  deficient  glandular  tissue.  There  are  some 
cases,  however,  of  insufficient  secretion  that  respond  promptly 
to  appropriate  treatment.  A  scanty  supply  of  milk  dependent 
upon  an  insufficient  diet  is  easily  corrected.  If  lactation  is  inter- 
rupted by  an  acute  febrile  attack,  nursing  may  be  successfully 
resumed  after  convalescence  is  established,  even  though  weeks 
and  occasionally  months  have  intervened.  I  have  seen  lactation 
begin  a  month  after  a  difficult  Cesarean  section  attended  with  pro- 
fuse hemorrhage  and  continued  successfully.  In  cases  of  general 
ill  health  or  constitutional  weakness,  much  may  be  effected  by  the 
administration  of  tonics  and  nutritious  diet  and  change  of  air  and 
scene.  If  the  deficient  secretion  is  dependent  upon  some  emotion, 
the  cause,  if  possible,  should  be  removed.  Electricity  has  been 
much  vaunted  as  a  remedy  for  insufficient  lactation.  It  may  be 
applicable  in  cases  of  torpidity  of  the  mammary  gland  or  in  those 
cases  in  which  lactation  was  not  practised  after  the  birth  of  the 
first  infant,  and  in  which,  therefore,  the  mammary  gland  does  not 
respond  readily  to  the  stimulus  of  subsequent  births.  This  remedy, 
however,  often  proves  ineffective  and  disappointing. 

There  is  no  medicinal  galactagogue  of  any  value.  If  three 
meals  a  day  of  food  suitable  to  the  patient's  condition,  reinforced 
by  four  glasses  of  milk  between  meals  and  fluid  extract  of  malt 
at  meals,  will  not  produce  a  sufficient  flow  of  milk,  the  child  must 
usually  be  artificially  fed. 

Quantitative  anomalies  by  excess  in  the  milk  secretion  may  take 
three  forms.  In  women  of  a  vigorous  physique,  well  nourished, 
and  of  a  full  habit,  the  supply  of  milk  is  likely  to  be  in  excess 
of  the  infant's  needs — polygalactia.  Lactation  maybe  continued 
far  beyond  the  usual  time — hyperlactation.  In  the  third  variety 
the  milk  continues  to  flow  from  the  breasts  in  varying  quantities 
and  for  varying  lengths  of  time  after  the  child  has  been  weaned 
or  when  it  has  not  been  suckled — galactorrhea. 

Polygalactia  is  exceedingly  common.  The  treatment  has  been 
referred  to  on  page  372.  Its  main  features  are  compression  and 
support  of  the  breast  by  a  mammary  binder,  the  administration 
of  laxatives,  the  regulation  of  the  diet,  and  the  evacuation  of  the 
breasts. 

Hyperlactation  is  more  frequently  met  with  among  the  poorer 
classes.  Infants  are  nursed  far  longer  than  they  should  be, 
either  from  the  fact  that  it  is  difficult  to  provide  food  for  another 
mouth  or  because  of  the  prevalent  belief  that  lactation  grants 
immunity  from    impregnation.      Women    have    been    known  to 


ANOMALIES  IN  MILK  SECRETION.  JO\ 

nurse  their  children  up  to  the  second  or  third  year.  Some 
women  and  certain  races  do  it  with  impunity.  Spanish  wet- 
nurses  suckle  three  or  four  successive  children  in  one  family. 
Japanese  women  habitually  nurse  their  children  for  five  or  six 
years.  Hyperlactation,  however,  usually  leads  to  serious  results. 
The  patient  becomes  exceedingly  weak,  pale,  and  thin.  The 
quantity  of  blood  is  diminished — oligemia.  There  are  loss  of 
appetite,  constant  headache,  pain  in  the  back,  languor,  and  de- 
rangement of  the  nervous  system.  Cramps  in  the  muscles  of  the 
neck  and  upper  extremities  occur  frequently;  they  appear  often 
during  the  day  and  last  for  varying  periods.  Suckling  the  child 
often  originates  an  attack.  There  is  especial  danger  of  phthisis 
in  women  of  tuberculous  tendency. 

The  treatment  of  hyperlactation  is  simple  and  effecti^'e.  The 
child  must  be  weaned  and  the  mother's  strength  restored  by  a 
nutritious  diet,  tonics,  and,  if  possible,  change  of  air. 

Galactorrhea  means  a  flow  of  milk  from  the  breasts  not  neces- 
sarily excited  by  the  suckling  child,  and  commonly  continued 
long  after  the  usual  term  of  lactation.  The  quantity  of  milk  ex- 
creted may  vary  from  a  {q.\\  grams  to  seven  liters  in  twenty-four 
hours. ^  Usually,  both  breasts  are  involved;  sometimes  only 
one.  The  cause  is  unknown.  It  has  been  attributed  to  a  relax- 
ation or  parah'sis  of  the  circular  muscular  fibers  surrounding  the 
milk-ducts,  but  this  is  an  effect  and  not  a  cause.  There  is  a 
case  recorded  of  galactorrhea  in  the  left  breast,  associated  with 
left  hemiplegia  occurring  after  child-birth.  ^  The  duration  is 
long,  extending  often  over  years.  There  is  a  case  reported  in 
which,  for  thirty  years,  there  Avas  an  uninterrupted  flow  of  milk 
from  the  breasts  of  a  woman  who,  at  the  time  of  the  report,  had 
reached  her  forty-seventh  year.  Curiously  enough,  her  health  had 
not  suffered.  Another  anomalous  feature  in  the  case  was  that  the 
return  of  the  catamenia  increased  the  flow  of  milk.^  I  have 
seen  a  woman  who  had  had  galactorrhea  for  eleven  years  after  a 
miscarriage  at  the  fifth  month.  Her  health  remained  perfect. 
The  usual  effect  of  a  long-continued  flow  of  milk  is  unfavorable, 
like  any  other  long-continued  discharge.  The  general  dcbilit}- 
from  this  cause  is  known  as  "tabes  lactca."  The  same  condition 
may  be  seen  in  extreme  cases  of  polygalactia  and  in  hyperlacta- 
tion. 

TrcatDioit. — The  most  prominent  feature  in  these  cases  is  the 
stubborn    resistance    that   they   offer,   as    a    rule,    to    treatment. 

1  Winckel,  "  Path.  u.  Therap.  des  Wochenbettes,"  p.  440. 

2  "Trans.  London  Obstet.  Sec.  for  1S87,"  xxix. 

■''  Green,  quoted  by  Gibbons,  "A  Case  of  Galactorrhea  (unilateral),"  ibid. 


702  PATHOLOGY  OF   THE   PUERPERIUM. 

There  are  two  measures,  however,  which  can  usually  be  depended 
upon  to  give  relief — firm  compression  of  the  mammary  gland  and 
the  administration  internally  of  iodid  of  potassium.  It  should  be 
remembered,  moreover,  that  in  many  cases  the  milk  secretion 
stops  spontaneously  with  the  return  of  menstruation,^  and  that 
in  a  certain  proportion  of  cases  a  treatment  adapted  to  securing 
a  discharge  of  blood  from  the  uterus  has  been  successful  in  cur- 
ing galactorrhea.  Abegg  was  successful  in  two  instances  in  stop- 
ping the  galactorrhea  by  the  use  of  warm  douches,  which  brought 
about  a  return  of  the  menses.  The  intra-uterine  application  of 
the  negative  pole  of  a  galvanic  current,  lo  to  12  milliamperes,  is 
the  best  treatment  to  bring  back  the  menstrual  flow.  Electricity 
has  been  recommended  to  secure  the  proper  contraction  of  the 
sphincter  muscles  of  the  lactiferous  ducts.  The  long-continued 
administration  of  ergot  has  been  successful,  and  its  use  is  rational. 
The  experiments  of  Roehrig  ^  have  demonstrated  that  drugs  causing 
an  increased  arterial  pressure  in  the  breasts  promote  milk  secre- 
tion, while  those  lowering  arterial  tension  tend  to  diminish  or 
even  abolish  the  function.  Chloral  was  shoAvn  to  be  peculiarl}r 
powerful  in  diminishing  the  quantity  of  milk;  therefore,  this 
drug  is  also  worthy  of  a  trial.  Belladonna  internally,  or  as  a 
local  external  application,  is  usually  employed  as  a  routine 
practice,  but  is  of  doubtful  utility.  It  has  been  claimed  that 
antipyrin,  in  2  i^ -grain  doses,  three  times  a  day.  diminishes  milk 
secretion.^ 

Qualitative  Anomalies  in  the  Milk. — The  most  important  factor 
influencing  the  constitution  of  the  milk  is  the  diet.  A  fatty  diet 
diminishes  the  quantity  of  milk.  A  vegetable  diet  diminishes 
the  casein  and  fat,  and  increases  the  sugar.  A  diet  rich  in  meat 
increases  the  fat  and  casein,  but  diminishes  the  sugar.  A  scanty 
diet  diminishes  all  the  solid  constituents  of  the  milk  except 
the  albumin. 

The  commonest  anomaly  in  the  constitution  of  the  milk,  in 
my  experience,  is  a  deficiency  of  fat  and  an  excess  of  casein. 
In  one  of  my  patients,  in  each  of  three  confinements  there  has 
been  a  milk  of  only  0.8  per  cent,  fat  and  3  per  cent,  albu- 
minoids. Usually  this  disordered  condition  of  the  milk  can  not 
be  remedied.  In  a  few  instances,  however,  qualitative  anomalies 
may  be  corrected  by  dietetic  management. 

The  effect  of  emotions  upon  the  constitution  of  the  milk  has 

1  Gibbons'  case;  Abegg' s  cases;  in  two  cases,  under  the  care  of  Depaul,  the 
galactorrhea  was  arrested  by  the  recurrence  of  pregnancy. 
^  Quoted  by  Gibbons. 
3  "  Bull.  gen.  de  Therap.,"  June,  1888. 


ANOMALIES  IN  MILK  SECRETION.  703 

already  been  referred  to.  B ar anger  ^  quotes  a  good  example: 
A  nursing  woman  saw  her  husband  threatened  by  a  soldier 
armed  with  a  saber.  Directly  afterward  she  gave  suck  to  her 
child.  It  seized  the  nipple  at  first  with  avidity,  then  refused  it, 
became  violently  convulsed,  and  died.  Every  practising  physician 
has  seen,  at  least  to  some  degree,  examples  of  the  change 
produced  in  the  milk  by  mental  impressions.  Becquerel  and 
Vernois  found  that  under  the  influence  of  emotion  the  milk  of  a 
woman  contained  more  water,  very  much  less  fat,  and  somewhat 
more  casein  than  was  found  in  the  mammary  gland  of  the  same 
individual  under  ordinary  circumstances.  Almost  all  acute 
febrile  affections  not  only  diminish  the  mammary  secretion,  but 
produce  some  change  in  its  constitution  and  make  it  indigestible. 
This  is  most  marked  in  the  prodromal  period.  If  a  chill  occurs, 
the  lacteal  secretion  is  suspended  almost  entirely  for  from  twelve 
to  twenty-four  hours. 

The  germs  of  some  diseases  pass  from  the  mother's  organism 
into  her  milk  ;  this  is  undoubtedly  true  of  tuberculosis.  It  is 
probable  that  the  germs  of  malaria  find  an  exit  from  the  body  in 
this  way.  Septic  micro-organisms  may  contaminate  the  milk 
from  the  breast,  although  the  mammary  gland  itself  is  free  from 
inflammation.  Karlinski^  has  reported  a  fatal  infection  of  the 
new-born  from  the  milk  of  a  puerpera  with  septic  fever.  Staphy- 
lococci were  found  in  the  milk. 

Women  under  the  influence  of  mercurialism  or  saturnism 
excrete  milk  of  abnormal  quality,  dependent,  perhaps,  as  much 
upon  the  anemia  associated  with  these  conditions  as  upon  the 
excretion  of  the  drug  itself.  The  influence  of  syphilis  upon  the 
consdtution  of  the  milk  is  not  yet  known.  It  has  been  asserted 
that  there  is  no  change  in  the  milk  of  syphilitic  women.  Vernois 
and  Becquerel,  on  the  other  hand,  affirm  that  there  are  well- 
marked  alterations  in  the  relative  proportions  of  the  different  in- 
gredients in  the  milk  from  syphilitic  women. 

Under  ordinary  circumstances  colostrum-corpuscles  may  be 
detected  in  human  milk  for  the  first  eight  or  ten  days  after  de- 
livery. There  are  certain  conditions  in  which  a  return  of  these 
corpuscles  may  be  noted.  They  reappear  sometimes  upon  the 
return  of  menstruation,  during  acute  mastitis,  or  in  any  other 
acute  affection  during  lactation.  Of  twenty-three  examinations 
made  by  Truman  ^  to  investigate  this  point,  colostrum-corpuscles 
were  found  present  in  the  following  cases  :   In  a  primipara  for 

1  "  Les  Centre- indications  et  Obstacles  S.  rAllaitement  maternal,"  "  Thdse  de 
Paris,"  1884. 

*  "  Zur  TEtiologie  der  I'uerperal-Infektion  der  Neugeborenen,"  "  Wien.  med. 
Wochenschr.,"  1888. 

3  «'  British  Med.  Jour.,"  1S8S,  ii,  p.  947. 


704  PATHOLOGY  OF   THE   PUERPERIUM. 

four  weeks  after  the  birth  of  a  premature  infant;  in  a  woman  who 
was  suckhng  her  four-month-old  baby  ;  in  a  non-pregnant  woman 
whose  infant,  born  twenty-six  months  before,  had  been  weaned 
for  ten  months  ;  in  a  non-pregnant  woman  who  had  been  married 
three  and  a  half  years  ;  ever  since  marriage,  for  a  week  before 
menstruation,  the  breast  filled  with  milk,  in  which  were  colos- 
trum-corpuscles ;  in  a  nursing  woman  who  had  never  been  able 
to  use  her  right  breast  during  lactation.  Her  last  child  was 
twelve  months  old.  In  the  milk  which  could  be  squeezed  out  of 
the  right  breast  colostrum-corpuscles  were  discovered.  Another 
case  was  one  of  chronic  ovaritis.  Twenty-three  months  had 
elapsed  since  the  last  labor,  and  eleven  since  weaning.  The 
milk  which  exuded  from  the  breast  contained  colostrum-cor- 
puscles. In  the  breast  of  a  woman  fifty-six  years  old,  which 
was  removed  for  carcinoma,  about  a  teaspoonful  of  milk  was 
found,  very  rich  in  colostrum-corpuscles.  This  woman's  young- 
est child  was  eight  years  old.  In  a  case  of  galactorrhea  which 
had  persisted  for  four  years  these  bodies  were  also  discovered. 
The  presence  of  colostrum-corpuscles  in  the  milk  is  not  a  proof, 
therefore,  of  a  recent  delivery. 

Anomalies  of  Color. — Blue  milk  is  due  to  the  presence  of  the 
bacillus  pyocyaneus;  yellow  and  green  milk  are  also  due  to  micro- 
organisms. Red  milk  may  be  the  result  of  infection  by  the  micro- 
coccus prodigiosus,  or  blood  may  be  excreted  by  the  gland,  as  a 
vicarious  menstruation  or  as  a  symptom  of  a  malignant  tumor. 

Diseases  of  the  Mammary  Glands. — Areola. — The  glands 
of  Montgomery  may  be  inflamed,  and  their  infection  may  lead 
to  mammary  abscess. 

Treatmejit. — Infection  of  the  areolae  should  be  avoided  by 
cleanliness.  Each  inflamed  and  suppurating  gland  should  be 
opened,  curetted,  and  its  interior  touched  with  strong  bichlorid 
solution. 

Exaggerated  pigmentation  of  the  areolae  often  persists  after 
pregnancy  ;  it  fades  away  in  the  course  of  lactation  or  after  the 
child  has  been  weaned. 

Congestion  and  engorgement  of  the  mammse  occur  in  almost 
every  case  on  the  tliird  day,  when  lactation  is  instituted. 

Treatment. — Excessive  congestion  may  be  avoided  by  admin- 
istering a  saline  purge  on  the  evening  of  the  second  day.  The 
breasts  must  be  thoroughly  evacuated  at  regular  intervals  by  the 
child's  mouth,  reinforced,  if  necessary,  by  massage  ^  and  a  breast- 

1  Bacon  claims  that  mammary  massage  to  empty  the  breasts  is  a  mistake  ;  that 
it  should  be  conducted  like  massage  of  a  swollen  joint  to  stimulate  the  blood  and  lymph 
circulation.  My  nurses,  however,  tell  me  that  the  method  described  and  illustrated 
in  the  text  proves  more  satisfactory  than  a  breast-pump.  Massage  of  the  breasts 
does  improve  the  circulation,  but  it  also  empties  the  breast.  See  "American  Journal 
of  Obstetrics,"  vol.  xlv,  No.  6,  1902. 


DISEASES  OF  THE  MAMMARY  GLANDS. 


70s 


\5  > 


c  ;;;  — 

-Ego: 


c  ii  'S  ^ 


"■•'So 


Fig.  539. — Massage  of  the  breasts. 


45 


7o6 


PATHOLOGY  OF  THE   PUERPERIUM. 


pump.  Hot  fomentations  may  give  great  comfort ;  but  if  the 
congestion  and  pain  persist,  lead-water  and  alcohol  is  the  best 
application.  A  mammary  binder  is  almost  always  a  necessary 
part  of  the  treatment.  The  pressure  and  support  which  it  affords 
contribute  more  than  any  other  single  item  in  the  management 
of  these  cases  to  prevent  excessive  congestion  and  disgorge- 
ment. 

From  the  investigations  of  Honigmann^  and  Ringel/  it 
appears  that  human  milk  contains  normally  the  staphylococcus 
pyogenes  albus,  as  well  as  the  staphylococcus  aureus.  These 
micro-organisms  wander  in  along  the  milk-ducts  from  the  skin. 
They  produce,  usually,  no  ill  results,  unless  the  vitality  of  the 
epithelial  cells  is  reduced  by  engorgement  of  the  gland  with  milk 


Fig.  540. — Breasts  disfigured  by  exaggerated  pigmentation  of  the  areolae. 


and  blood,  as  in  the  "caked  breast."  They  may  then  take  an 
active  part  in  the  development  of  a  mammary  abscess,  by  attack- 
ing the  epithelial  cells  of  the  milk-ducts,  destroying  them,  and 
invading  the  surrounding  connective  tissue. 

Sore  Nipples. — Excoriations  and  fissures  of  the  nipples  are 
due  to  the  maceration  and  irritation  to  which  they  are  subjected 
by  the  child's  gums  and  mouth.  Mammary  abscess  not  infre- 
quently results  from  the  entrance  of  streptococci  or  of  other  in- 
fectious bacteria  through  these  fissures. 

Prophylactic  Treatment. — During  the  latter  months  of  preg- 
nancy the  nipple  should  be  washed  twice  a  day,  and  should  then 

'  F.  Honigmann,  "  Bakteriologische  Untersuchungen  ueber  Frauenmilch,"  In- 
aug.-Diss.,  Breslau,  1893. 

''■  Ringel,  "  Ueber  den  Keimgehalt  der  Frauenmilch,"  "  Miinchen.  med.  Woch- 
enschr.,"  1894,  No.  27. 


DISEASES    OF   THE   MAMMARY  GLANDS. 


707 


be  touched  with  a  piece  of  clean  absorbent  cotton,  saturated  with 
a  mixture  of  glycerol  of  tannin  and  water,  equal  parts.  Alco- 
holic astringents  should  be  avoided.  It  is  necessary  to  keep 
the  nipple  clean  during  lactation  by  bathing  it  after  each  nurs- 
ing with  boric  acid  solution  (gr.  x  to  fSj),  and  to  keep  the  skin 


Fig.  541. — Breast-pump. 


Fig.  542. — Nipple-shield. 


in  a  healthy  condition  by  frequent  applications  of  sweet-oil,  until 
the  nipple  becomes  accustomed  to  its  functions. 

Curative  Treatment. — The  nipple  should  be  carefully  cleansed 
after  each  nursing,  and  one  of  the  following  remedies  should  be 
applied  to  it :  An  ointment  composed  of  oij  each  of  bismuth 
subnit.  and  castor  oil  ;  tinct.  benzoin  comp.,  applied  directly  to 
the  fissure.  Iodoform,  gr.  x,  to  ung.  zinci  oxidi,  5ss  ;  ichthyol,  oj  ; 
lanolin,  glycerin,  each  siss  ;  olive  oil,  siiss.  The  fissure  may  be 
touched  with  a  solution  of  nitrate  of  silver  (gr.  x  to  the  ounce) 
or  with  the  solid  stick.  A  nipple-shield  is  almost  always  neces- 
sary. It  must  be  perfectly  clean,  and  should  be  kept  immersed 
in  cool  water  while  not  in  use.  In  cases  of  supersensitive  nip- 
ples, without  abrasions  or  cracks,  or  if  the  latter  are  slight  in  de- 
gree, extract  of  witch-hazel  is  an  excellent  remedy.  It  is  often 
advisable  to  protect  the  nipples  between  the  nursings  by  lead 
nipple  shields,  which  guard  them  against  the  rubbing  of  clothing 
or  of  the  mammary  binder.  Occasionally  the  nipples  are  so 
exquisitely  sensitive  that  the  pressure  of  a  night-gown  or  of  the 
bed-clothes  is  unendurable,  although  there  is  no  fissure,  crack, 
abrasion,  or  inflammation.  In  such  cases  nerve-sedatives  in- 
ternally, lead  nipple  shields,  and  cocain  as  a  local  application  are 
necessary.      Usually,  the  child  must  be  weaned. 

Inflammations  of  the  Breasts— Mastitis. — There  may  be  an  in- 
flammation of  the  subcutaneous   connective  tissue  of  the  mam- 


7o8 


PATHOLOGY  OF   THE   PUERPERIUM. 


5:!S^~^'^@^'-§r  '5^-^ 


%11^^ 


mary  gland,  of  the  deeper  interstitial  tissue,  or  of  the  parenchyma. 
A  septic  inflammation  is  rarely  confined  strictly  to  one  of  these 

localities.  There  is  usually 
involvement  of  all  the  tissues 
in  the  gland. 

As  in  all  puerperal  infec- 
tions, the  micro-organisms 
responsible  for  the  inflam- 
mation ma}^  be  of  many- 
pathogenic  varieties.  The 
constitutional  symptoms  of 
mammary  infection  are  usu- 
ally slight,  but  ma}'  be  very 
severe,  even  though  the  local 
inflammation  appears  to  be 
moderate. 

Causes. — The  first  two 
classes,  superficial  and  inter- 
stitial mastitis,  are  due  to 
sepsis,  the  result  of  direct  in- 
oculation. The  sources  of 
infection  are  unclean  fingers, 
contaminated  water,  soiled 
rags  to  dry  the  nipple,  dirt}' 
cloths  laid  over  the  breasts, 
and  stomatitis  in  the  infant.  Parenchymatous  inflammation  need 
not  always  be  ascribed  to  this  cause.  Overactivity  of  the  gland, 
engorgement  with  blood,  and  distention  with  milk  (the  so-called 
"  caked  breast  ")  ma}'  be  primarily  responsible  for  the  infectious 
inflammation  b}'  weakening  the  resisting  power  of  the  cells 
against  microbic  invasion. 

Treatment. — If  the  inflammation  is  parenchymatous  and  is  due 
to  oversecretion,  the  breast  must  be  emptied  with  a  pump  or  by 
massage  (see  Fig.  539),  and  must  be  supported  by  a  binder. 
If  the  inflammation  is  confined  to  the  connective  tissue  and  sup- 
puration is  threatened,  lead-water  and  alcohol  should  be  applied 
with  a  mammary  binder.  Suckling  had  best  be  intermitted  if  the 
inflammation  continues  and  an  abscess  is  threatened,  as  the  irrita- 
tion of  nursing  may  increase  the  mammary  congestion  and  the  milk 
is  apt  to  disagree  with  the  child.  It  has  rarely  given  rise  to  septic 
infection  of  the  child's  intestines  by  its  contained  micro-organisms. 
Bier's  treatment  of  local  hyperemia  by  a  vacuum  apparatus 
(Fig.  544)  has  been  highly  recommended  in  congestion  and  threat- 
ened suppuration  of  the  breast.  I  gave  it  a  thorough  trial  for  a 
year  with  unsatisfactory  results.  It  is  painful  and  no  more 
efficient  than  the  measures  described  above. 


Fig-  543- — Puerperal  mastitis  forming 
abscess  :  a.  Group  of  acini  melted  to  pus 
(Billroth). 


DISEASES   OF  THE  MAMMARY  GLANDS. 


709 


Mammary  Abscess. — The  pus  may  be  located  superficially, 
in  the  gland-substance,  or  in  the  submammary  connective  tissue, 
as  a  postmammary  abscess. 

The  symptoms  of  suppuration  are  uncertain.  The  reddened 
skin,  the  swelling  and  sensitiveness  of  the  breast,  and  the  fever 
may  be  due  simply  to  intense  congestion.  Fluctuation  is  rarely 
detected  until  late,  and  should  not  be  awaited.    A  dusky-red  hue 


Fig.  544. — Various  sizes  and  shapes  of  Bier's  cups  for  the  breast,  with  the  syringe, 

to  create  a  vacuum. 

of  the  skin,  and  edema,  with  fever,  are  the  most  valuable  signs  of 
suppuration,  and  should  indicate  an  immediate  incision  or  incisions. 
Treatment. — A  mammary  abscess  must  be  incised  as  soon  as 
the  physician  is  satisfied  that  there  may  be  pus  within  the  breast. 
It  is  much  better  to  make  an  unnecessary  incision  than  to  allow 
the  pus  to  burrow  through  the  gland 
until  the  operation  for  the  woman's 
relief  becomes  quite  formidable.  If 
the  abscess  is  opened  early,  one 
incision  commonly  suffices.  If  the 
case  is  neglected,  every  pocket  of 
pus  must  be  opened  and  every  sinus 
must  be  drained  to  secure  a  prompt 
and  permanent  cure.  I  have  made 
as  many  as  eighteen  incisions  in  the 
two  breasts,  and  have  had  half  that 
number  of  drainage-tubes  through 
the  glands  in  a  woman  who  had 
been  ill  for  six  weeks  or  more  with 
mammary  abscesses,  in  spite  of  a  few 
ineffective  and  insufficient  incisions 
in  the  breasts,  made  from  time  to 
time  by  her  medical  attendant.      In 

incising  a  mammary  abscess,  the  incisions,  so  far  as  possible, 
should  radiate  from  the  nipple,  so  that  they  run  parallel  with 
the  lacteal  ducts.      Otherwise,   a    duct  may  be  cut  across   and 


Fig.  545. — Pigment  of  the 
areola  following  incisions  (Rich- 
ardson). 


710 


PATHOLOGY  OF   THE   PUERPERIUM. 


a  lacteal  fistula  may  result.  The  incision  should,  if  possible, 
avoid  the  area  of  pigmentation,  or  should  be  confined  wholly 
within  it,  as  the  pigmentation  follows  the  cut,  disfiguring  the 
breast  (see  Fig.  545).  The  incisions  should  be  made  through 
the  skin  with  a  knife,  the  opening  being  only  large  enough  to 
admit  a  moderate-size  drainage-tube.  The  abscess-cavities  should 
be  punctured  with  a  hemostat,  inserted  closed  and  withdrawn 
open.  After  evacuating  the  pus  and  inserting  the  drainage- 
tubes,  which  are  pulled  through  from  one  opening  to  another  by 
dressing-forceps,  the  breast  is  covered  with  sterile  gauze  and  is 
compressed  by   a  firm   mammary  binder.      The  drainage-tubes 


Fig.  546. — Drainage  required  in  a  case  of  mammary  abscess. 


should  be  irrigated  with  sterile  water  daily  by  a  straight-tipped 
medicine-dropper  attached  to  a  fountain  syringe  and  inserted  in 
the  end  of  each  tube.  The  average  time  for  convalescence  is 
two  weeks.  It  is  claimed  that  Bier's  apparatus  is  an  effective 
and  quick  means  of  evacuating  mammary  abscesses  through  one 
or  more  small  punctures.  The  usual  rules  for  the  application 
of  this  apparatus  are  followed :  forty-five  minutes  at  a  time,  four 
minutes  on,  four  minutes  off.     I  tried  it  in  a  number  of  cases,  but 


DISEASES   OF   THE   MAMMARY  GLANDS.  71I 

in  each  instance  was  obliged  to  give  it  up  in  favor  of  multiple  in- 
cisions and  counter-drainage. 

In  the  case  of  postmammary  abscess,  the  whole  breast  is 
lifted  off  the  chest,  and  there  are  no  signs  of  suppuration  within 
the  gland  itself.  The  systemic  symptoms  of  this  kind  of  mam- 
mary abscess  are  usually  severe. 

Treatment. — The  incision  should  be  made  beyond  the  per- 
iphery of  the  gland  at  the  most  dependent  part  as  the  woman  lies 
on  her  back,  and  a  counteropening  must  be  made  upon  the 
opposite  side.  A  drainage-tube  is  passed  under  the  gland  by  a 
dressing-forceps,  and  the  cavity  is  irrigated  daily. 

A  galactocele  is  a  milk-tumor  due  to  occlusion  of  one  of  the 
lactiferous  ducts.  It  is  usually  of  no  pathological  importance, 
unless  it  should,  as  rarely  happens,  reach  a  large  size,  when  it 
must  be  tapped  and  drained. 

Other  mammary  tumors,  especially  adenomata,  may  take  on  a 
very  rapid  growth  in  pregnancy,  and  may  become  so  engorged 
and  painful  when  lactation  begins  that  their  removal  is  necessary. 
In  one  of  my  cases  an  adenoma  grew  during  pregnancy  from  the 
size  of  a  walnut  to  that  of  a  cocoanut,  and  I  was  obliged  to  excise 
it  on  the  third  day  of  the  puerperium. 

Relaxation  of  the  Pelvic  Joints. — The  pelvic  joints,  after 
labor,  may  be  the  seat  of  inflammation,  accompanied  by  serous 
exudation,  and  ending  possibly  in  suppuration.  In  the  case  of 
the  symphysis  pubis,  the  abscess  can  easily  be  opened  and  drained. 
The  prognosis,  therefore,  is  good.  In  the  other  pelvic  joints  sup- 
puration is  commonly  fatal.  The  pelvic  joints  may  be  ruptured 
by  violence  during  labor.  This  accident  is  considered  in  connec- 
tion with  the  forceps  operation  and  injuries  to  the  woman  in 
labor.  Finally,  there  may  be  relaxation  of  the  pelvic  joints  to  a 
marked  degree,  much  exaggerated  beyond  that  seen  in  almost 
every  pregnant  woman,  and  persisting  after  delivery. 

The  etiology  is  obscure.  Abnormal  motion  in  the  pelvic 
bones  has  been  seen  in  justomajor  pelves.  It  has  been  noted 
after  abortion.  It  may  be  traced  to  a  large,  hard  fetal  head 
which  had  stretched  the  joints.  It  occurs  in  justominor  pelves 
rather  frequently.  It  has  been  ascribed  to  obesity,  to  a  cachectic 
condition,  to  sudden  and  powerful  exertion  in  the  latter  months 
of  pregnancy,  to  an  unusually  great  circumference  of  the  preg- 
nant uterus,  1  and  to  previous  disease  or  abnormality  of  the  joint.  ^ 

The  diagnosis  is  easy.  There  is  difficult  locomotion,  unusual 
mobility  in  the  joints,  especially  the  symphysis  pubis,  and  local- 
ized pain.  The  woman  may  not  be  able  to  stand  on  her  feet  at 
all,  or  to  take  a  step  without  collapsing.      The  examination   is 

1  Winckel,  "  Geburtshiilfe,"  p.  873. 

2  Schauta,  in  Miiller's  "  llandbuch,"  vol.  ii. 


712  PATHOLOGY  OF   THE   PUERPERIUM. 

best  made  in  the  erect  posture,  the  physician  placing  a  fore- 
finger behind  and  his  thumb  in  front  of  the  symphysis.  As  the 
patient  takes  a  step  forward  and  backward  the  abnormal  mobility 
of  the  innominate  bones  is  appreciable.  If  the  woman  cannot 
stand,  the  examination  is  made  in  the  dorsal  position,  an  assist- 
ant flexing,  extending,  abducting,  and  rotating  one  thigh. 

The  treatment  is  rest  in  bed  with  the  application  of  a  firm 
binder  about  the  hips  reinforced  sometimes  by  sand-bags.  In 
the  course  of  a  few  weeks  the  joints  usually  become  firm.  Oc- 
casionally, the  relaxation  persists  for  months.  I  have  not  yet 
seen  a  case  that  did  not  recover  under  the  treatment  described  :. 
Kelly  reports  one  in  which  he  resected  the  symphysis  and  wired 
the  pubic  bones  together. 


CHAPTER  II. 
Ptterperal   Sepsis. 


Historical. — The  history  of  the  acquisition  of  our  knowledge 
of  puerperal  infection  is  distinctly  modern.  It  had  its  earliest 
beginning  about  fifty  years  ago,  and  dates  back  in  reality  scarcely 
thirty  years.  Indeed,  one  may  say  that  a  true  comprehension 
of  the  causes  and  nature  of  puerperal  sepsis  was  acquired  only 
at  the  close  of  the  nineteenth  century,  and  that  the  past  i&w 
years  have  contributed  more  information  on  the  subject  than  all 
the  previous  ages  of  medicine. 

The  history  of  medical  views  on  the  septic  fevers  of  the 
puerperium  prior  to  the  past  generation  is  a  long  record  of 
error  and  ignorance.  From  the  earliest  beginning  of  medi- 
cal literature  to  the  nineteenth  century,  puerperal  sepsis  was 
ascribed  to  suppression  of  the  lochia.  This  belief  was  not  ques- 
tioned until  1670,  when  Puzos  advanced  the  theory  that  all  puer- 
peral fevers  were  due  to  a  metastasis  of  milk,  which  fio\yed  in 
the  blood  during  pregnancy,  and  was  normally  attracted  to  the 
breasts  after  delivery,  but  which  might  be  drawn  to  other  organs 
or  structures,  especially  the  peritoneum,  with  disastrous  results. 
This  theory  found  support  in  the  reports  of  a  number  of  post- 
mortem examinations,  stating  that  milk  had  been  discovered  in 
the  peritoneal  cavity  after  deaths  following  childbirth. 

A  little  later  English  and  German  observers  explained  the 
puerperal  infectious  fevers  by  attributing  them  to  inflammations 


PUERPERAL    SEPSIS.  ^l^ 

of  the  womb  and  of  the  peritoneum,  without  accounting  satis- 
factorily for  the  occurrence  of  the  inflammation.  Occasionally, 
one  finds  a  reference  to  putrid  fevers  in  the  puerperium,  a  sug- 
gestion that  putrefying  animal  matter  may  occasion  disease  in 
human  bodies  with  which  it  comes  in  contact,  an  intimation  of 
the  contagiousness  of  puerperal  fever ;  but  these  were  mere 
glimmerings  of  light  that  flickered  out  at  once  without  illumi- 
nating the  general  ignorance.  Credit,  however,  must  be  given 
to  some  of  the  English  writers  of  the  first  half  of  the  nineteenth 
century  for  insisting  upon  the  contagiousness  of  puerperal  fever. 

Three  events  laid  the  foundation  of  our  present  knowledge 
of  puerperal  sepsis  :  The  publication  of  Oliver  Wendell  Holmes' 
paper  on  "The  Contagiousness  of  Puerperal  Fever,"  in  1843; 
the  observations  of  Semmelweiss  in  the  Vienna  Hospital,  1846- 
'48  ;  the  publication  of  Sir  James  Y.  Simpson's  paper  on  "  The 
Analogy  between  Puerperal  and  Surgical  Fevers,"  in  1850. 

The  first  of  these  papers  must  always  remain  a  classic  in 
medical  and  English  literature.      It  ended  with  these  words  : 

"  I  have  no  wish  to  express  any  harsh  feeling  with  regard  to 
the  painful  subject  which  has  come  before  us.  If  there  are  any 
so  far  excited  by  the  story  of  these  dreadful  events  that  they 
ask  for  some  word  of  indignant  remonstrance  to  show  that 
science  does  not  turn  the  hearts  of  its  followers  into  ice  or  stone, 
let  me  remind  them  that  such  words  have  been  uttered  by  those 
who  speak  with  an  authority  I  could  not  claim.  ^  It  is  as  a 
lesson  rather  than  as  a  reproach  that  I  call  up  the  memory  of 
these  irreparable  errors  and  wrongs.  No  tongue  can  tell  the 
heart-breaking  calamity  they  have  caused  ;  they  have  closed  the 
eyes  just  opened  upon  a  new  world  of  love  and  happiness  ;  they 
have  bowed  the  strength  of  manhood  into  the  dust ;  they  have 
cast  the  helplessness  of  infancy  into  the  stranger's  arms,  or 
bequeathed  it,  with  less  cruelty,  the  death  of  its  dying  parent. 
There  is  no  tone  deep  enough  for  regret,  and  no  voice  loud 
enough  for  warning.  The  woman  about  to  become  a  mother,  or 
with  her  new-born  infant  upon  her  bosom,  should  be  the  object 
of  trembling  care  and  s\'mpathy  wherever  she  bears  her  tender 
burden  or  stretches  her  aching  limbs.  The  very  outcast  of  the 
streets  has  pity  upon  her  sister  in  degradation,  when  the  seal  of 
promised  maternity  is  impressed  upon  her.  The  remorseless 
vengeance  of  the  law,  brought  down  upon  its  victim  by  a 
machinery  as  sure  as  destiny,  is  arrested  in  its  fall  at  a  word 
which  reveals  her  transient  claim  for  mercy.  The  solemn  pra)'er 
of  the  liturgy  singles  out  her  sorrows  from  the  nuiltiplicd  trials 
of  life,  to   plead  for  her  in   the   hour  of  peril.      God  forbid  that 

1  Dr.  Blundell  and  Dr.  Rigl)y,in  the  works  already  cited. 


714  PATHOLOGY  OF   THE   PUERPERIUM. 

any  member  of  the  profession  to  which  she  trusts  her  life,  doubly 
precious  at  that  eventful  period,  should  hazard  it  negligently, 
unadvisedly,  or  selfishly! " 

This  unanswerable  arraignment  of  the  prevailing  views  in 
America  in  regard  to  puerperal  sepsis  fell  upon  deaf  ears.  The  very 
men  who  should  have  first  recognized  its  truth  opposed  the  new 
doctrine  with  all  their  might,  because  it  contradicted  their 
teaching.  At  that  time,  in  America,  two  men  were  so  pre- 
eminent in  obstetrics  that  they  were  practically  without  rivals, 
and  autocratically  dictated  their  views  to  a  large  number  of  un- 
questioning followers.  They  were  Hodge  and  Meigs,  holding, 
respectively,  the  Chairs  of  Obstetrics  in  the  University  of  Penn- 
sylvania and  in  the  Jefferson  Medical  College. 

Meigs  directed  against  Holmes'  teaching  all  the  satire  and 
ridicule  of  which  his  brilliant  mind  was  capable,  descending  often 
to  undignified  abuse  ;  Hodge  inveighed  against  it  with  a  pon- 
derous invective.  But  in  spite  of  this  powerful  opposition  the 
doctrine  of  the  contagiousness  of  puerperal  fever  made  rapid 
headway,  and  gained  from  year  to  year  an  increasing  number  of 
converts  in  America  and  in  England.  Hodge's  immediate 
successor,  Dr.  Penrose,  taught  it  most  impressively. 

In  1846,  Ignaz  Philipp  Semmelweiss,  a  young  assistant  in 
the  Maternity  Department  of  the  General  Hospital  of  Vienna, 
was  struck  with  the  frightful  mortality  in  one  of  the  maternity 
wards,  while  in  a  neighboring  ward  the  death-rate  was  scarcely 
one -tenth  as  great.  He  discovered  that  in  the  first  ward  the 
women  were  attended  by  students  who  were  in  the  habit  of  com- 
ing fresh  from  postmortem  examinations  in  the  Pathological  De- 
partment to  the  bedside  of  the  parturient  patients.  In  the  second 
the  women  were  attended  solely  by  midwives.  Semmelweiss 
conceived  the  idea  that  the  students  carried  on  their  hands  putrid 
products  from  the  postmortem  table  to  the  lying-in  women  whom 
they  examined,  and  that  these  products  were  responsible  for  the 
large  number  of  fatal  inflammations  and  fevers  following  their 
work.  He  consequently  ordered  that  no  student  should  exam- 
ine a  woman  until  he  had  washed  his^  hands  in  chlorin-water. 
The  results  were  fairly  startling,  as  is  shown  in  the  accompany- 
ing table: 

Confinements.  Deaths.  Per  Cent. 

1846, 4010  459  II. 4 

1847, 3490  176  5- 

1848, 3556  45  1-27 

It  should  be  stated  that  the  rule  compelling  the  students  to 
wash  their  hands  in  an  antiseptic  solution  was  put  into  effect  in 
the  middle  of  the  year  1847. 

Semmelweiss  recognized  the  transcendent  importance  of  his 


PUERPERAL    SEPSIS.  715 

discovery.  He  foresaw  something  of  the  lives  preserved,  the 
homes  kept  from  bereavement,  the  mothers  saved  to  their  chil- 
dren, the  wives  to  their  husbands,  in  milhons  of  famihes  ;  the  in- 
calculable diminution  of  human  suffering  which  his  discovery 
promised  to  the  world  ;  but  his  was  not  the  calm  and  confident 
soul  of  a  Harvey,  wise  enough  to  know  that  the  truth  is  mighty 
and  shall  prevail  :  sure  that  mankind  must  accept  it  some  day, 
and  content  to  bide  his  time.  Semmelweiss'  nature  was  not 
great  enough  for  such  patience.  He  fumed  and  fretted  his  life 
away  in  vain  efforts  to  obtain  recognition  for  his  principle  of 
chemical  disinfection.  He  preached  his  new  doctrine  in  season 
and  out  of  season,  endeavoring  to  impress  it  upon  his  'mme- 
diate  colleagues,  and  upon  the  medical  societies  and  periodi- 
cal medical  literature  of  the  time  in  Europe.  During  the  latter 
days  of  his  professorship  in  Buda-Pesth  he  would  even  stop 
acquaintances  upon  the  street  to  importune  them  with  his  views. 
But  he  got  for  his  pains  nothing  but  ridicule,  contumely,  opposi- 
tion, or  indifference.  He  finally  lost  his  mind  entirely,  from  chagrin 
and  disappointment,  ending  his  life  in  a  lunatic  asylum  in  Vienna, 
where  he  died,  strangely  enough,  from  a  septic  wound  on  his 
finger,  received  during  an  operation  performed  just  before  his 
commitment  to  the  asylum. 

More  than  twenty  years  after  Semmelweiss'  discovery,  the 
mortality  of  many  lying-in  hospitals  in  Europe  remained  as  high 
as  ten  per  cent.  Then  came  the  brilliant  work  of  Pasteur  in 
the  field  of  bacteriology,  the  acceptance  of  the  germ  theory  in 
disease,  the  application  of  antisepsis  to  surgery  by  Lister,  and 
the  adoption  of  the  system  almost  immediately  by  obstetricians. 
From  that  day  to  this  there  has  been  a  steady  and  increasingly 
rapid  acquisition  of  knowledge  of  the  etiology  of  septic  infection, 
and  of  its  most  successful  preventive  and  curative  treatment. 

It  is  to  be  hoped  that  the  medical  world  of  to-day  and  of  the 
future  can  never  again  be  deaf  and  blind  to  such  an  appeal  as 
that  of  Holmes,  or  to  such  a  demonstration  as  that  of  Semmel- 
weiss. 

Etiology. — It  has  become  necessary  to  study  the  normal 
and  abnormal  microbic  flora  of  the  vagina  in  order  to  under- 
stand fully  the  etiology  of  puerperal  infection,  and  to  comprehend 
the  safeguards  that  nature  affords  a  woman  against  infection 
after  labor. 

The  effective  study  of  the  subject  dates  from  Doderlein's 
monograph  published  in  1892.^  Before  this  time  the  presence 
of  bacilli  in  vaginal  secretions  was  noted  by  Hausmann,  Conner, 

'  "  Das  Scheidensekret  uiid  seine  Bedeutung  fiir  das  Puerperal-Fieber,"  Albert 
Doderlein,  Leipsic,  1892. 


7i6 


PATHOLOGY  OF  THE  PUERPERIUM. 


Bumm,  Winter,  and  Steffeck.  Conner,  in  1887,  found  in  vaginal 
secretions  many  varieties  of  micro-organisms,  mainly,  however, 
bacilli,  which  were  extremely  difficult  to  cultivate  in  the  ordinary 
culture  media.  The  cocci  in  the  secretions,  many  of  which 
could  be  cultivated  with  ease,  were  found  to  be  non-pathogenic. 

Conner  concluded  that  the  vaginal  secretions  contained  no 
pathogenic  bacteria. 

Bumm  also  failed  to  find  pathogenic  germs  in  the  vagina. 

Winter  believed  that  pathogenic  germs  were  present  in  the 
vagina  in  a  state  of  lessened  or  absent  virulence. 

Doderlein  examined  the  vaginal  secretions  of  195  pregnant 
women.     In  these  examinations  notice  was  taken  of  the  macro- 


Fig.   547. — Vaginal    secretion    of   an  Fig. 

infant  (Doderlein). 


548. — Vaginal    secretion    of 
virgin  (Doderlein). 


scopical  appearance  and  of  the  reaction  of  the  secretions,  and 
as  the  result  of  this  preliminary  examination  the  secretions  were 
declared  to  be  normal  or  abnormal.  In  the  two  conditions  the 
bacteriological  find  was  quite  different.  Jn  the  normal  secretion, 
which  was  of  whitish  color,  of  the  consistency  of  curdled  milk,  un- 
mixed with  mucus,  containing  epithelial  cells  and  mucous  bodies, 
moistened  by  an  exudate  from  the  vaginal  mucous  membrane 
and  of  an  intensely  acid  reaction,  there  was  found  almost  exclu- 
sively a  certain  kind  of  bacillus  possessed  of  distinctive  and 
characteristic  qualities.  No  pathogenic  germ  was  ever  found  by 
Doderlein  in  normal  vaginal  secretions,  except  a  thrush-fungus 
which  is  capable,  to  a  very  limited  extent,  of  producing  suppura- 
tion and   destruction   of  tissue  when  injected  under  the  skin  or 


PUERPERAL  SEPSIS. 


717 


into  the  eye  of  an  animal.  In  the  pathological  abnormal  secre- 
tion, which  was  yellowish  or  greenish  in  color,  of  the  consistency 
of  cream,  weakly  acid  or  alkaline  in  reaction,  mixed  with  mucus, 
containing  often  bubbles  of  gas  and  secreted  usually  in  very  large 
quantities,  the  greatest  variety  of  cocci  and  bacilli  could  be  found. 
Of  the  195  pregnant  women,  Doderlein  found  that  55.3  per 
cent,  had  normal  and  44.6  per  cent,  had  pathological  secretions. 

Although  a  number  of  observers  had  found  bacilli  in  the 
vaginal  secretions  before  Doderlein,  no  one  had  so  carefully 
studied  their  characteristics,  functions,  and  cultivation  ;  so  that 
they  are  properly  called  the  vaginal  bacilli  of  Doderlein.  They 
are,  according  to  him,  anaerobic.  They  have  no  motion.  They 
produce  by  their  life -process  an  acid  medium  by  forming  lactic 


Fig.  549. —  Normal  secretion  of  a  preg- 
nant woman  (Doderlein). 


Fig.  550.  —  Pathological  secretion  of  a 
pregnant  woman  (DoderleinJ. 


acid.  They  are*  frequently  associated  with  a  yeast-fungus 
(thirty-six  per  cent,  in  normal  secretions  only),  which  Doderlein 
believes  to  be  identical  with  the  thrush-fungus,  Saccharomyces 
albicans. 

The  vaginal  bacilli  are  antagonistic  to  staphylococci,  which 
within  certain  limits  they  have  the  power  to  destroy.  This  was 
shown  by  several  experiments,  among  others  by  infecting  the 
vagina  of  a  virgin  with  staphylococcus  cultures  in  large  quanti- 
ties. Within  four  days  the  staphylococci  had  disappeared,  and 
no  bacteria  remained  within  the  vagina  except  the  vaginal 
bacillus. 

Doderlein  attributes  the  germicidal  action  of  the  normal 
vaginal   secretion  to  the  production   of  an  acid   environment  by 


71  8  PATHOLOGY  OF  THE  PUERPERIUM. 

the  vaginal  bacillus.      He  supports  this  view  by  the  following 
facts  : 

1.  That  all  pathological  secretions  swarming  with  sapro- 
phytes and  with  many  pathogenic  germs  are  weakly  acid  or 
alkaline. 

2.  That  in  a  puerpera  the  vaginal  bacillus  disappears  and  in 
its  place  are  found  many  kinds  of  saprophytes,  the  lochial 
discharge  being  alkaline. 

3.  That  when  the  lochia  ceases  the  saprophytes  disappear, 
the  vaginal  bacillus  reappears,  and  the  vaginal  secretion  becomes 
again  intensely  acid. 

In  only  8  out  of  the  195  cases  examined  were  streptococci 
found,  and  in  only  5  of  these  cases  was  it  possible  to  demon- 
strate by  inoculation  experiments  that  the  streptococci  were 
virulent.  In  2  cases  the  streptococcus  possessed  no  virulence 
at  all. 

These  discoveries  of  Doderlein  have  not  been  universally 
accepted.  His  views  have  not  gone  unchallenged,  and  further 
interesting  properties  of  the  vaginal  secretions  have  been  pointed 
out  by  others,  but  we  may  safely  acknowledge  Doderlein's 
conclusions  to  be  correct  in  the  main,  so  far  as  they  go,  and  that 
his  discoveries  constitute  the  most  important  advance  in  the 
knowledge  of  this  subject  achieved  by  a  single  individual. 

Following  Doderlein's  investigation  there  have  appeared  a 
number  of  exhaustive  studies,  the  most  important  conclusions 
of  which  may  be  briefly  summarized  as  follows  : 

In  series  of  examinations  conducted  by  Burgubru,  Williams, 
Stroganoff,  and  Burkhardt,  in  12,  15,  9,  and  16  cases  respect- 
ively, streptococci  were  found  in  i,  3,  2,  and  5.  Taking  the 
sum-total  of  all  these  cases  with  Doderlein's,  streptococci  were 
found  twenty-seven  times  in  542  women  examined,  showing  that 
in  only  a  small  proportion  of  cases  are  dangerous  pathogenic 
germs  to  be  found  in  the  vaginal  secretions  of  pregnant  women  ; 
and  accepting  Doderlein's  results  as  correct  along  with  those 
of  Winter,  in  the  few  cases  in  which  streptococci  were  found,  a 
considerable  proportion  of  the  streptococci  were  non-virulent. 

Kronig,  1  in  about  :^oo  examinations,  found  that  the  vagina  in 
pregnant  women,  aside  from  the  gonococcus  and  the  thrush- 
fungus,  contained  no  pathogenic  micro-organisms.  The  strepto- 
coccus was  not  found  in  a  single  case.  Adding  these  examina- 
tions to  the  former  series,  the  proportion  of  cases  in  which  the 
streptococcus  may  be  found  is,  as  appears,  still  further  reduced. 

1  "  Deutsche  med.  Wochenschr. ,"  1894,  Oct.  24,  p.  819. 


PUERPERAL  SEPSIS.  719 

Moreover,  Kronig  found,  after  inoculating  the  vagina  with  pure 
cultures  of  streptococcus,  staphylococcus,  and  bacillus  pyocy- 
aneus,  that  none  of  these  micro-organisms  could  be  discovered 
after  eleven  to  twenty  hours. 

Kronig  attributes  the  germicidal  properties  of  the  vagina,  which 
are  demonstrated  by  these  observations,  mainly  to  the  flow  out- 
ward of  the  vaginal  secretions,  and  not  to  any  special  microbe 
having  its  normal  habitat  in  the  vagina.  According  to  this 
observer,  acid,  neutral,  and  alkaline  secretions  all  have  germi- 
cidal power.  Further,  Kronig  found  that  if  an  hour  after  the 
infection  of  the  vagina  an  antiseptic  douche  of  lysol  were  admin- 
istered, not  only  were  the  infecting  micro-organisms  not  de- 
stroyed by  the  douche,  but  also  that  it  took  the  vaginal  secretions 
from  nineteen  to  thirty-six  hours  to  destroy  microbes  that  with- 
out the  douche  would  disappear  in  from  eleven  to  twenty  hours. 

These  results  were  confirmed  by  Menge/  in  a  study  of  the 
germicidal  power  of  vaginal  secretions  in  non-pregnant  women, 
except  that  Menge  occasionally  did  find  streptococci  in  the 
vagina.  From  a  number  of  observations  and  experiments  this 
observer  forms  the  following  conclusions  as  to  the  causes  of  the 
germicidal  power  of  vaginal  secretions,  putting  them  down  in 
the  order,  as  he  believes,  of  their  importance  : 

The  antagonism  of  the  normal  microbic  flora  of  the  vagina 
and  of  the  pathogenic  micro-organisms  which  may  be  deposited 
there  by  accident. 

The  products  of  the  life-process  of  the  vaginal  bacilli. 

The  acidity  of  the  secretions. 

The  germicidal  powers  of  the  anatomical  elements  of  the 
vagina. 

The  leukocytosis  which  is  provoked  by  chemotaxic  action 
either  of  the  vaginal  discharges  or  of  the  infecting  micro-organ- 
ism invading  the  vagina. 

The  phagocytosis  following  leukocytosis. 

The  absence  of  free  oxygen  in  the  vagina. 

Walthard/  from  the  bacteriological  study  of  the  vagina  in  100 
women  ante  el  post  parfum,  concludes  that  the  genital  canal  of 
women  is  divided  practically  into  two  parts — one  infected,  the  other 
sterile.  The  former  comprises  the  vestibule,  the  vagina,  and  lower 
portion  of  the  cervical  canal.  The  latter,  the  upper  portion  of  the 
cervical  canal,  the  uterine  cavity,  and  the  tubal  canals.  The 
causes  of  this  division  of  the  canals,  according  to  Wallhard,  are: 

I.  The  plug  of  mucus  stopping  up  the  cervical  canal,  which, 
though  not  in  itself  germicidal,  is  deficient  in  albuminoids  and  fur- 
nishes no  nutriment  for  micro-organisms. 

'  "  Deutsche  med.  Wochenschr.,"  1S94,  Oct.  24,  p.  819. 
^  "Archiv  f.  Gyn.,"  vol.  xlviii,  p.  201. 


720  PATHOLOGY  OF  THE  PUERPERIUM. 

2.  The  leukocytes,  which  are  found  in  great  numbers  where 
the  cervical  secretion  mixes  with  the  vaginal  secretion  at  the 
level  of  the  external  os. 

According  to  this  observer,  there  are  really  three  divisions 
of  the  genital  canal  :  one,  the  lower,  containing  leukocytes  and 
bacteria  ;  the  next,  containing  only  leukocytes,  and  the  third,  the 
upper,  containing  neither  leukocytes  nor  bacteria. 

It  is  supposed  that  the  outpour  of  leukocytes  is  due  to  a 
chemotactic  action  excited  by  the  mixture  of  cervical  and  vaginal 
discharges,  and  that  the  phagocytosis  follows  naturally  the  leu- 
kocytosis. 

In  the  vaginal  discharges  Walthard  found,  both  during  preg- 
nancy and  after  delivery,  pathogenic  microbes,  streptococci, 
staphylococci,  gonococci,  and  the  colon  bacilli.  The  first 
named  were  found  in  27  out  of  the  100  women  examined, 
but  these  streptococci  had  lost  all  virulence  and  had  become 
veritable  saprophytes.  Inoculation  experiments  with  them  pro- 
duced no  results — that  is,  if  they  were  inserted  in  normal  tissues  ; 
but  if  a  certain  region  of  the  animal's  body  was  reduced  in 
vitality,  or  if  the  condition  of  the  animal's  system  was  lowered 
in  any  way,  the  inoculation  of  the  streptococci  produced  abscesses 
in  which  the  micro-organisms  rapidly  regained  all  their  original 
virulence  until  they  became  quite  as  deadly  as  the  most  danger- 
ous of  their  kind.  From  his  experiments  and  observations, 
Walthard  draws  the  following  conclusions  : 

The  virulence  of  vaginal  streptococci  of  a  pregnant  woman 
not  examined  for  some  time  is  equal  to  that  of  the  streptococci 
that  live  upon  other  mucous  membranes  or  in  their  secretions. 
In  other  words,  the  vaginal  streptococci  are  not  virulent,  and 
behave  as  saprophytes  upon  healthy  tissues  ;  but  as  in  the  case 
of  the  intestinal  streptococci,  the  vaginal  streptococci  can  become 
infectious  when  the  resistance  of  the  tissues  with  which  they  are 
in  contact  is  diminished.  The  virulence  that  the  vaginal  strep- 
tococci attain  under  these  circumstances  is  quite  equal  to  that  of 
the  streptococci  of  puerperal  infection. 

Stroganoff,^  from  an  examination  of  eleven  pregnant  women, 
supports  Doderlein's  assertion  that  the  vaginal  bacillus  pro- 
duces by  its  development  lactic  acid,  and  shows  that,  while 
the  vaginal  secretions  of  the  new-born  are  very  weakly  acid, 
they  become  more  and  more  acid  as  bacteria  develop  in  the 
vagina.  He  quotes  experiments  of  Schlutter,  showing  that  an 
acid  medium  retards  the  growth  of  the  staphylococcus  and  is 
destructive  to  the  streptococcus  of  erysipelas.  He  further  shows, 
by  experiments  with  culture  media,  that  the  vaginal  bacillus  pro- 
duces not  only  an  acid  medium,  but  also  other  products  of  its 

1  "  Monats.  f.  Geb.  u.  Gyn.,"  Bd.  ii,  p.  3S1. 


PUERPERAL  SEPSIS.  72 1 

life-processes  that  retard  or  prevent  the  growth  of  the  staphylo- 
cocci. 

In  these  experiments  the  vaginal  bacillus  was  cultivated,  and 
the  culture  then  raised  to  a  high  temperature,  so  that  the  bacilli 
were  destroyed.  The  culture  was  then  inoculated  with  the 
staphylococcus  pyogenes  albus,  with  negative  result.  If  the 
culture,  in  addition  to  being  treated  as  described,  was  made  alka- 
line, the  staphylococci  grew,  but  not  so  vigorously  as  upon  the 
same  culture  medium  in  which  the  vaginal  bacillus  had  not  been 
grown. 

Stroganoff  explains  the  sterility  of  the  upper  cervical  canal 
and  of  the  uterine  cavity  by  the  active  germicidal  properties  of 
the  cervical  mucus,  by  the  mechanical  action  of  the  flow  of  men- 
strual blood,  by  the  same  action  of  the  descending  placenta  and 
membranes,  and  by  that  of  the  lochial  discharge.  Perhaps  there 
should  be  added  the  germicidal  effect  of  blood  itself,  which 
propert}'  it  has  been  recently  demonstrated  that  blood  possesses, 
to  a  certain  extent. 

Stroganoff  announces  the  following  conclusions  from  his 
study  :  One  finds  in  the  vagina  of  pregnant  women  always  a 
quantity  of  micro-organisms.  The  prominent  form  in  normal 
cases  is  the  bacillus,  but  there  are,  in  addition,  usually  other  forms 
present.  Micro-organisms  which  liquefy  gelatin  are  met  with 
comparatively  seldom  in  normal  cases,  and  then  onh'  in  small 
numbers.  A  pathological  condition  of  the  vaginal  mucous  mem- 
brane alters  the  normal  flora.  The  vaginal  secretion  of  pregnant 
women  is  strongly  acid  in  reaction.  In  addition  to  micro- 
organisms, one  sees  usually  under  the  microscope  epithelial  cells 
and  isolated  white  blood-corpuscles.  The  cervix  contains  nor- 
mally no  micro-organisms.  When  they  are  present  in  that  situ- 
ation, their  number  is  small.  The  reaction  of  the  cervical 
secretion  is  alkaline.  In  not  a  single  case  were  there  organisms 
in  the  cervix  which  liquefied  gelatin.  The  external  os  is  usually 
the  boundary  between  that  portion  of  the  genital  canal  which 
contains  micro-organisms  and  that  portion  which  does  not. 

Kottmann,^  with  a  special  apparatus  to  prevent  contamina- 
tion, finds  pathogenic  micro-organisms  in  a  considerable  pro- 
portion of  the  pregnant  women  examined.  Williams,^  on  the 
contrary,  claims  that  the  vagina  is  free  from  pathogenic  germs. 

Vahle^  finds  that  for  the  first  twenty -four  hours  the  vaginal 
secretions  of  new-born  infants  are  sterile.  By  the  third  day 
they  always  contain  micro-organisms,  and  in  a  considerable  pro- 

i"Arch.  f.  Gyn.,"  Bd.  Iv.  II.  3. 
^  "  Am.  Jour.  ofObstet.,"  vol.  xxxviii. 
^  "  Zeitschr.  f.  Geb.  u.  Gyn.,"  Bd.  xxxii,  II.  3,  v. 
46 


722  PA THOL OGY  OF  THE  P UERPERIUM. 

portion  of  cases  the  staphylococcus  pyogenes  albus  and  aureus 
and  a  streptococcus. 

Stroganoff  finds  that  within  a  few  hours  of  birth  the  vagina 
becomes  infected,  and  that  in  a  certain  proportion  of  cases  the 
inoculation  occurs  in  utcro,  or  during  the  passage  of  the  child's 
body  through  the  vagina.  This  is  most  likely  to  occur  in  breech 
presentations.  A  great  variety  of  micro-organisms  may  be  found 
in  the  vagina  of  the  newly  born,  including  streptococci,  diplo- 
cocci,  staphylococci,  etc. 

Stolz^  finds  streptococci,  bacilh  and  cocci  in  the  vagina.  Nat- 
vig^  finds  streptococci  in  a  state  of  diminished  virulence  on  the 
vulva,  which  are  easily  carried  or  wander  into  the  vagina  and 
uterus,  regaining  their  virulence  in  these  situations.  Procopio 
and  De  Angelis,  investigating  the  presence  of  the  colon  bacillus  in 
the  vagina,  found  vaginal  secretions  sterile  in  70  per  cent,  of  the 
cases,  cervical  secretions  sterile  in  91.6  per  cent.^  Michni*  finds 
trimethylamin  in  vaginal  secretions  and  attributes  to  it  decided 
bactericidal  properties. 

From  this  mass  of  facts,  set  down  without  any  special  order, 
confusing  in  its  complexity  and  occasionally  in  its  apparent 
contradictions,  the  practical  physician  may  draw  the  following 
conclusions  as  to  the  etiology  of  puerperal  sepsis:  The  vulva, 
like  any  other  skin  surface,  such  as  the  physician's  hands,  may  be 
infected  with  pathogenic  bacteria,  and  from  its  situation  is  most 
likely  to  be  surgically  unclean.  jNIicro-organisms  on  the  vulva  may 
be  diminished  in  virulence,  but  may  become  actively  infectious 
if  transplanted  deep  within  the  genital  canal.  The  vagina  be- 
comes infected  almost  immediately  after  birth.  In  a  normal 
condition  it  contains  no  pathogenic  bacteria,  but  occasionally 
streptococci,  staphylococci,  and  other  pathogenic  micro-organisms 
are  resident  in  the  vagina  before  labor.  These  germs,  if  present, 
are  usually  diminished  in  virulence,  but  may  regain  their  full 
pathogenic  power  under  conditions  favorable  to  their  growth  and 
propagation.  The  vaginal  canal  has  strong  germicidal  proper- 
ties which  serve  to  guard  a  woman  against  infection.  They 
depend  upon  the  presence  of  a  special  bacillus,  and  upon  the 
products  of  its  life-processes;  upon  the  leukocytosis  due  to 
chemotactic  action ;  upon  phagocytosis;  upon  the  germicidal 
powers,  perhaps,  of  the  anatomical  elements  of  the  vagina ;  of 
the  cervical  mucus,  and  of  the  bloody  discharge  during  menstru- 
ation and  the  puerperium,  and  possibly  upon  the  presence  of  tri- 
methylamin. 

^  "  Studien  zur  Bakteriologie   des  genitalkanales  in  der  Schwangerschaft  u.  im 
Wochenbette,"  Graz,  1903  ;  alsoHegar's  "Beitrage  zur  Geb.  u.  Gyn.,"  Bd.  vii,H.3. 
2  "Arch.  f.  Gyn.,"  Bd.  Ixxvi,  H.  3. 
^  "  Arch,  di  Ostet.  e.  Gin.,"  1906,  p.  385.  *  "  jahresbericlit,''  p.  94,  vol.  xvi. 


PUERPERAL   SEPSIS.  723 

During  and  after  labor,  mechanical  safeguards  of  the  most 
effective  kind  are  furnished  against  infection.  These  are  :  the 
discharge  of  the  liquor  amnii,  washing  the  vagina  out ;  the 
passage  of  the  child's  body,  scrubbing  the  vagina  out ;  the 
descent  of  the  placenta  and  membranes,  and  the  bloody  dis- 
charge which  follows. 

Moreover,  should  the  vagina  contain  pathogenic  bacteria, 
they  are  likely  to  be  in  a  condition  of  diminished  or  absent  viru- 
lence, in  which  they  will  not  be  productive  of  disease. 

Bearing  these  facts  in  mind,  it  is  apparent  that  the  common 
practice  of  relying  upon  simple  vaginal  douching  for  disinfecting 
the  vagina  before  labor,  or  before  some  gynecological  manoeuver 
or  operation,  is  faulty,  not  to  say  fooHsh.  It  has  been  clearly 
demonstrated  that  the  injection  of  an  antiseptic  fluid  into  the 
vagina  does  not  destroy  pathogenic  germs  there,  and  robs  the 
woman,  to  a  certain  extent,  of  the  safeguards  that  nature  pro- 
vides for  her  against  infection.  If,  therefore,  under  certain  cir- 
cumstances, it  is  desirable  to  disinfect  the  vagina,  mere  douching 
should  not  be  depended  upon,  but  the  vaginal  mucous  membrane 
should  be  thoroughly  scrubbed  out  as  well  as  douched,  just  as 
one  would  prepare  the  skin  for  an  important  surgical  operation. 

It  is  clear  that  these  remarkable  discoveries  in  regard  to  the 
micro-organisms  normally  present  in  the  vagina  do  not,  in  the 
slightest  degree,  lessen  the  importance  of  antiseptic  precautions 
on  the  part  of  medical  or  other  attendants  upon  a  patient  in 
labor.  The  presence  of  the  organisms  in  the  vagina  might 
possibly  be  used  as  an  argument  against  the  necessity  for  anti- 
septic precautions.  For,  it  might  be  said,  the  vagina  being 
already  infected,  it  is  unnecessary  to  observe  such  elaborate  pre- 
cautions against  infecting  it  still  more. 

But  when  one  considers  that  the  micro-organisms  in  the  lower 
genital  canal  are  not  pathogenic  in  the  vast  majority  of  cases,  and 
that  when  they  are  their  virulence  is  diminished  or  absent,  it  is 
obviously  incumbent  upon  any  conscientious  man  not  to  insert 
into  the  vagina  infecting  bacteria  which  may,  by  their  number  and 
virulence,  overcome  all  the  safeguards  that  nature  provides,  and 
may,  consequently,  be  the  cause  of  a  serious  and  fatal  disease. 

The  Pathogenic  Microbes  Capable  of  Producing!:  Local  In= 
flammation  and  General  Systemic  Infection  when  Introduced 
in  the  Genital  Canal. — Streptococci  were  first  observed  in  cases 
of  puerperal  infection  by  Mayerhofer  in  1865  and  were  first 
cultivated   from   such   cases   by   Pasteur  in    18S0. '        Doderlcin 

'  See  the  very  instructive  article,  wiili  lull  |jilili(]<;ra|ili\-,  hv  [.  W.  Williams,  on 
"Puerperal  Infection"  in  "The  I'ractice  of  Obstetrics  l)\-  American  Authors," 
Jewett,  1899. 


724  PATHOLOGY   OF   THE    PUERPERIUM. 

found  the  streptococcus  pyogenes  as  the  sole-infecting  agent  in 
five  cases  of  serious  puerperal  infection. 

Czerniewski,  in  53  cases  of  puerperal  infection,  found  strepto- 
cocci in  49.  In  a  histological  and  bacteriological  examination 
of  16  cases  of  puerperal  fever,  Widal  found  streptococci  in  14, 
bacilli  in  2.  Bumm,  in  an  examination  of  17  cases  of  puerperal 
infection,  found  streptococci  in  all — 5  times  as  pure  cultures,  12 
times  mingled  with  small  numbers  of  staphylococci  and  of  other 
germs.  Thus,  in  a  total  of  91  cases,  the  streptococcus  was 
found  to  be  the  infecting  agent  in  85,  or  94  per  cent. 

Following  streptococci,  but  a  long  way  behind  as  the  cause 
of  puerperal  infection,  are  the  pyogenic  staphylococci,  the  colon 
bacillus,  the  gonococcus,  the  tubercle  bacillus,  the  bacillus  pyocy- 
aneus,  the  bacillus  foetidus,  the  pneumococcus,  the  Klebs-Loffler 
bacillus  of  diphtheria,  the  tetanus  bacillus,  and  possibly  any  germ 
at  all  that,  inserted  into  living  tissues  or  deposited  upon  weakly  re- 
sisting surfaces,  is  capable  of  causing  local  inflammation  or  gen- 
eral disease.  In  addition  to  specific  septic  micro-organisms,  the 
anaerobic  saprophytes  of  decomposition  play  an  important  role 
in  the  common  form  of  puerperal  sepsis,  due  to  the  absorption 
of  toxins,  or  ptomains  produced  in  the  decomposition  of  dead 
animal  matter,  such  as  blood-clots,  fragments  of  placenta,  hyper- 
trophied  decidua,  within  the  womb.  Dobbin  ^  has  reported  an 
interesting  case  of  fatal  puerperal  infection,  in  which  the  bacillus 
aerogenes  capsulatus  (gas  bacillus)  was  probably  the  infecting 
agent,  or,  at  least,  produced  the  toxins  that  fatally  intoxicated 
the  maternal  organism,  and,  after  death,  developed  the  samie 
emph}'sema  in  the  maternal  body  which  was  found  in  the  dead 
and  macerated  fetus  at  the  time  of  delivery.  This  germ  is 
accountable  for  cases  of  physometra,  or  tympanites  uteri.  It 
develops  by  preference  in  dead  bodies,  and  may  not  manifest  its 
presence  during  life.  It  finds  in  the  dead  fetus  within  the  womb 
a  habitat  most  suitable  for  its  development  ;  it  gives  rise  to 
a  horribly  fetid  inflammable  gas,  and  probably  to  virulent 
toxins.^ 

Blumer  ^  reports  a  case  of  mixed  puerperal  and  typhoid  infec- 
tion in  which  the  streptococcus  and  the  typhoid  bacillus  were 
isolated  both  from  the  blood  and  the  uterine  cavity. 

J.  Whitridge  Williams,  of  Baltimore,  in  an  examination  of 
forty  patients,   the  cultures    being   taken   from  the  ward    cases 

1  "Puerperal  Sepsis  due  to  Infection  with  the  Bacillus  Aerogenes  Capsulatus," 
"Johns  Hopkins  Hospital  Bulletin,"  No.  71,  February,  1897. 

2  See  also  studies  of  five  cases  by  Lindenthal,  "Beitrage  zur  Aetiologie  des 
Tympania  Uteri,"  "  Monatschr.  f.  Geb.  u.  Gyn.,''  Bd.  vi,  p.  269. 

3  "Am.  Jour,  of  Obstet.,"  Jan.,  1899. 


PUERPERAL    SEPSIS.  J 2^ 

whenever  the  temperature  went  to  or  above  ioi°  F.  and  from 
the  out-door  cases  when  it  reached  102°,  found — 

Streptococci  in 8  cases 

Staphylococci  in ,    .  2  cases 

Colon  bacilli  in 6  cases 

Strictly  anaerobic  bacteria  in 4  cases 

Unidentified  aerobic  bacteria  in    .    .    .         .  .         .    -  5  cases 

Bacteria  were  found  in  cover-glass  examinaiions,  all  cul- 
tures being  sterile,  in 4  cases 

Diphtheria  bacilli  in I  case 

Bacillus  aerogenes  capsulatus  in I  case 

Typhoid  bacilli  in  .    .  i  case 

Malarial  plasmodia  in  blood,  cultures  sterile,  in     .    .    .  I  case 
No  bacteria   on    cover-glass,    cultures   sterile  and  blood 

negative,  in II  cases 

making  a  total  of  44  cases,  the  difference  between  that  number 
and  the  40  cases  actually  examined  being  due  to  the  fact  that 
there  were  mixed  infections  in  several  instances. 

The  Manner  in  which  Pathogenic  Organisms  Find  an 
Entrance  into  the  Genital  Canal. — The  majority  of  puerperal 
infections  are  traceable  to  the  insertion  of  pathogenic  germs  by 
the  examining  finger  or  hand  of  the  physician,  who  in  the  course 
of  his  daily  work  may  have  touched  the  dried  sputum  of  diph- 
theria, the  desquamated  skin  of  scarlet  fever,  suppurating  wounds, 
erj'sipelatous  surfaces,  and  other  virulent,  infectious  material ; 
so  that  at  any  time  his  hands  may  fairly  reek  with  the  most 
dangerous  poisons  that  could  possibly  be  brought  in  contact 
with  the  parturient  and  puerperal  woman.  Many  hundred  cases 
have  been  traced  directly  to  the  association  of  the  physician  with 
infectious  diseases,  and  there  is  scarcely  a  surer  way  of  avoiding 
puerperal  infection  than  by  abstention  from  vaginal  examinations. 
Epidemics  of  puerperal  fever  in  hospitals  have  been  quickly 
stamped  out  by  avoiding  all  internal  examinations,  and  the  best 
morbidity  and  mortality  records  have  been  obtained  in  institu- 
tions in  which  vaginal  examinations  are  eliminated  as  much  as 
possible.  Even  if  the  examining  hand  is  protected  by  a  sterile 
glove,  pathogenic  bacteria  may  be  carried  into  the  vagina  from  the 
vulva,  if  there  is  a  faulty  technique  in  making  the  examination. 
The  hands  of  the  nurse  or  other  attendants  may  be  the  agents  that 
deposit  bacteria  in  the  vagina  or  uj)on  the  vulvar  orifice.  The 
implements  used  in  and  about  the  parturient  canal,  an  atmosphere 
laden  with  dust  or  vitiated  by  foul  unhygienic  conditions,  and  the 
water  used  to  wash  and  douche  the  patient  m.ay  carry  disease  germs 
to  the  parturient  woman  and  may  introduce  them  into  the  genital 
canal.  The  bed-clothing,  the  personal  clothing,  the  mattress,  the 
vulvar  pads,  the  material  used  to  cleanse  the  vulva  (rags,  sponges, 
cotton,  cloths),  may  each  and  all  be  sources  of  infection. 


J 26  PATHOLOGY  OF   THE   PUERPERIUM. 

Putrescible  material  retained  within  the  genital  canal  (espe- 
cially within  the  uterine  cavity)  attracts  the  innumerable  and 
ubiquitous  saprophytes  and  their  spores,  with  which  the  purest 
atmosphere  swarms.  The  development  of  these  bodies  in  a 
situation  most  favorable  to  their  growth  and  active  propagation 
may  easily  result  in  a  toxemia,  if  not  in  actual  invasion  of  the 
body  by  pathogenic  germs. 

Coitus  in  the  last  weeks  of  pregnancy  is  said  to  be  a  source  of 
infection  of  the  genitaha  in  exceptional  cases,  by  carrying  patho- 
genic bacteria  into  the  vagina.  Finally,  a  certain  proportion  of 
cases  may  be  traced  to  autoinfection — that  is,  to  pathogenic  germs 
resident  in  the  body,  and  not  introduced  from  without  during  or 
after  labor.  These  germs  may  have  had  a  lodgment  in  the  vagina, 
as  has  been  demonstrated  in  the  bacteriological  studies  of  that  canal; 
or  they  may  have  been  contained  in  a  limited  area  near  the 
genital  canal,  as  in  an  old  pyosalpinx,  whence  they  spread  by 
rupture  of  the  pus-sac  during  labor,  or  in  which  they  are  incited 
to  new  activity  by  the  compression  and  consequent  reduction  of 
vitality  of  surrounding  tissue.  There  may  have  been  tuberculosis 
of  the  genitalia,  antedating  conception.  Or  there  may  be,  in  the 
neighborhood  of  the  uterus,  tumors  of  low  vitality  and  highly  put- 
rescible material,  which,  being  reduced  in  resisting  power  by  com- 
pression from  the  descending  child,  become  infected  by  germs 
that  ordinarily  can  not  influence  vigorous  body-cells.  Dermoid 
cysts  and  fibroid  tumors  are  the  best  examples  of  these  growths. 

Even,  highly  vitalized  tissues  like  the  pelvic  muscles,  espe- 
cially the  iliopsoas,  may  be  so  bruised  and  injured  by  the  child's 
head. that  they  slough  and  become  gangrenous.  The  iliac  bone, 
too,  has  become  carious  after  the  bruising  to  which  it  was  sub- 
jected in  a  prolonged  forceps  operation. 

The  parturient  woman  may  have  had  an  infectious  interstitial 
endometritis.  The  micro-organisms  being  lodged  in  the  interstices 
of  the  mucosa,  and  the  woman  becoming  pregnant,  there  is  con- 
tained in  the  uterine  cavity,  even  before  conception,  a  cause  of 
puerperal  sepsis. 

The  Behavior  of  Pathogenic  Micro=organisms  when  Intro= 
duced  into  the  Genital  Canal  or  Deposited  upon  its  Entrance.^ 
— The  consequences  of  microbic  invasion  of  the  genital  canal  by 
pyogenic  germs  are  variable  in  the  extreme.  If  the  bacteria  enter 
wounds  in  or  near  the  vaginal  outlet,  the  result  maybe  the  same 
as  in  the  infection  of  any  wound  in  general  surgery — that  is  to 
say,  local  inflammation,  suppuration,  and  perhaps  general  sys- 
temic  infection  ;  but   the   infectious   inflammation    of   a   vaginal 

*  "  Ueber  die  im  weiblichen  Genitalcanale  voikonimenden  Bakterien  in  ihrer 
Eeziehung  zur  Endometritis,"  "Arcbiv  f.  Gyn.,"  Bd.  1,  H.  3. 


PLATE    l6. 


Streptococcic  infection  of  the  vagina  and  vulva,  with  pseudomembrane.     Cured  by- 
local  irrigation,  general  stimulation,  and  support  (University  Hospital). 


PUERPERAL    SEPSIS.  72/ 

wound  is  almost  certain  to  spread  upward,  for  the  conditions  are 
more  favorable  to  microbic  growth  and  to  systemic  invasion  in 
the  uterine  cavity  and  in  the  tubal  canals  than  in  the  lower 
portion  of  the  genital  tract.  Hence  it  is  that  the  vast  majority 
of  serious  puerperal  infections  have  their  effective  starting-point 
within  the  womb.  For  example,  it  has  been  found,  in  a  strepto- 
coccic infection  of  the  whole  genital  tract,  that  the  micro- 
organisms were  present  in  the  vaginal  mucous  membrane  alone, 
in  the  cervical  mucous  membrane,  and  in  the  tissues  immedi- 
ately subjacent ;  in  the  endometrium,  and  deep  within  the  uterine 
muscle,  showing  that  they  could  easily  penetrate  the  deeper 
tissues  within  the  womb,  while  they  were  incapable  of  invading 
the  tissues  underlying  the  vaginal  mucous  membrane.  In  other 
words,  the  resisting  power  of  the  tissues  under  the  mucous  mem- 
brane is  less  the  higher  the  micro-organisms  are  found  in  the 
genital  canal. ^ 

Septic  infection  of  the  genital  tract  results  often  in  the  forma- 
tion of  false  membranes.  This  is  true  of  pure  streptococcic 
infections,  of  mixed  infections  (streptococcus,  bacillus  foetidus, 
bacillus  pyocyaneus,  the  pyogenic  staphylococci),  and  especially 
true,  of  course,  of  the  rare  cases  of  true  diphtheria  of  the 
genital  tract  in  which  the  Klebs-Loffler  bacillus  is  found.  The 
apparent  false  membrane  in  a  septic  endometritis  is  due  to  a 
necrosis  of  the  endometrium,  clothing  the  uterine  walls  with  a 
dirty,  greenish-yellow  covering. 

There  is  much  yet  to  learn  of  the  antagonisms  and  associations 
of  pathogenic  germs  in  puerperal  infections.  This  much,  however, 
may  be  asserted  with  confidence  :  the  streptococcus  is  frequently 
associated  with  the  pyogenic  staphylococci,  the  bacillus  foetidus, 
the  bacillus  pyocyaneus,  and  the  colon  bacillus,  though  it  is 
said  to   drive  away  or  to    destroy  the  staphylococci  after  a  time. 

The  gonococcus  seems  often  to  prepare  the  way  for  the  strep- 
tococcus, which,  in  its  turn,  may  destroy  the  gonococcus,  con- 
quering the  latter  in  a  struggle  for  existence  and  remaining  in 
sole  possession  of  the  field.  The  streptococcus  appears  often  to 
prepare  the  way  for  the  colon  bacillus,  which  certainly  wanders 
in  frequently  in  the  course  of  streptococcic  infection. 

Streptococci,  staphylococci,  and  the  pyogenic  bacilli  have 
preeminently  the  power  to  penetrate  the  tissues  of  the  uterus 
and  to  distribute  themselves  throughout  the  body.  This  is 
particularly  true  of  the  streptococci. 

Gonococci  and  the  colon  bacilli  confine  themselves  most 
often  to  the  endometrium  and  to  the  tubal  mucosa.  The  former 
is   tlic   pathogenic  agent  in   a   large  proportion  of  the  cases  of 

'  Lahn,  "  Jiiuug.  Diss.,"  Jahresbericht,  1894. 


728  PATHOLOGY  OF   THE   PUERPERIUM. 

septic  endometritis  after  labor.  The  latter  is  often  found  in  cases 
of  physometra.  Both  of  these  organisms,  however,  can  pene- 
trate the  uterine  muscle,  and  may  be  distributed  through  the 
system  by  the  lymph-channels  or  by  the  blood-vessels.  Strep- 
tococci show  a  preference  for  the  lymphatic  channels  in  their 
invasion  of  the  tissues.  Hence  they  usually  pass  from  the  endo- 
metrium to  the  myometrium,  to  the  parametrium,  and  to  the 
subperitoneal  lymphatics,  perhaps  affecting  the  tubes  and  ova- 
ries, secondarily,  perhaps  causing  abscesses  or  general  infection 
of  the  peritoneal  cavity,  or  of  the  pelvic  connective  tissue.  The 
putrefactive  micro-organisms  (saprophytes)  are  anaerobic,  and 
confine  their  activity  mainly  to  the  decomposition  of  putrescible 
uterine  contents,  particularly  of  hypertrophied  endometrium, 
which  is  practically  cut  off  from  its  blood-supply  by  the  contrac- 
tion of  the  womb,  and  is  peculiarly  liable  to  rapid  decomposi- 
tion. During  the  process  of  putrefaction  the  saprophytes  manu- 
facture soluble  and  absorbable  products  (toxins)  of  a  highly 
pathogenic  nature,  causing  possibly  a  fatal  intoxication  without 
actual  microbic  invasion  of  the  body.  Moreover,  saprophytes 
occasionally  attack  blood-clots  in  the  uterine  sinuses,  and  may. 
be  swept  into  the  general  circulation  by  detachment  of  a  thrombus 
and  deposited  as  a  septic  embolus  in  different  portions  of  the 
body,  causing  metastatic  abscesses.  It  is  claimed  also  that  the 
bacteria  of  putrefaction  and  their  toxins  increase  the  virulence  of 
streptococci. 

Symptoms  and  Diagnosis  of  Puerperal  Infection.— The 
symptoms  of  puerperal  infection  are  local  and  general.  The 
latter  are  :  an  elevated  temperature,  preceded  perhaps  by  a  chill  ; 
a  rapid  pulse,  and  profound  physical  depression,  with  the  devel- 
opment in  some  cases  of  metastatic  inflammations  of  any  of  the 
organs  or  tissues  in  the  body.  The  tongue  is  coated  ;  the  breath 
is  heavy.  There  is  a  disinclination  to  take  food.  There  may  be 
intense  thirst ;  nausea  and  vomiting  are  not  uncommon,  and  a 
septic  diarrhea  appears  in  the  worst  cases.  There  may  be 
blotches  of  a  scarlatiniform  eruption  upon  the  skin. 

The  local  symptoms  of  septic  infection  are  :  a  foul  discharge, 
redness  of  the  mucous  membrane,  spots  of  ulceration  and  false 
membrane  formation  along  the  lower  genital  canal,  edema  of  the 
vulva,  and,  possibly,  pelvic  peritonitis  with  an  exudate.  Or  there 
may  be  other  inflammatory  affections  of  the  generative  organs, 
such  as  superficial  catarrhal  colpitis  or  ulcerative  metritis,  the 
symptoms  of  which  are  described  in  their  appropriate  places. 
It  is  not  likely  that  any  case  of  puerperal  sepsis  will  present  all 
the  symptoms  just  detailed.  Elevation  of  temperature  and  rapid 
pulse  alone  after  labor  should  be  regarded  as  indicative  of  puer- 
peral infection  if  no  other  cause  for  them   can  be  demonstrated. 


PUERPERAL    SEPSIS.  729 

It  is  possible,  indeed,  to  see  elevation  of  temperature  alone  as 
a  symptom  of  puerperal  infection  in  the  early  part  of  the  puer- 
perium,  during  which  time  the  influences  that  normally  reduce 
the  pulse-rate  are  so  active  as  to  counteract  the  disposition  to 
rapidity  of  pulse  usually  shown  in  septic  infection.  The  slow 
pulse,  however,  does  not  continue  long.  At  the  end,  usually,  of 
thirt}^-six  hours,  rapid  heart-action  appears. 

It  may  be  difficult  to  make  a  differential  diagnosis  between 
septic  fever  and  some  of  the  other  causes  of  elevated  temperature 
after  labor.  In  these  cases  it  is  wise  to  treat  the  patient  for 
puei-peral  sepsis  by  a  thorough  disinfection  of  the  parturient  tract, 
while  at  the  same  time  the  bowels  are  well  evacuated  and  a  full 
dose  of  quinin  is  administered  to  dispose  of  a  possible  intestinal 
toxemia,  and  to  combat  a  possible  malarial  infection  which  in 
many  parts  of  the  country,  especially  in  the  spring  and  fall,  is  a  not 
improbable  event. 

A  microscopic  examination  of  the  blood  is  always  advisable 
in  a  doubtful  case,  to  discover  the  leukocytosis  of  sepsis  or  the 
protozoa  of  malaria. 

Typhoid  fever  may  be  most  difficult  to  distinguish  from  puer- 
peral infection.  The  difficulty  is  increased  in  some  cases  by  the 
fact  that  a  Widal  reaction  may  occasionally  be  obtained  in  strepto- 
coccic infection  and  that  there  may  be  a  mixed  infection  by  the 
bacillus  typhosus  and  streptococci.  Blood-cultures  have  enabled 
me  to  make  a  diagnosis  of  typhoid  fever  in  several  cases  referred 
to  the  Maternity  with  the  idea  that  they  were  streptococcic  infec- 
tions. 

The  appearance  and  number  of  the  blood-corpuscles  is  of 
interest  in  all  cases  of  sepsis  and  may  have  distinct  diagnostic 
value.  Leukocytosis  should  be  marked  at  first,  unless  the 
system  is  overwhelmed  with  septic  intoxication.  The  absence 
of  leukocytosis,  therefore,  in  a  grave  case  is  unfavorable,  kn.  ex- 
acerbation of  the  leukocytosis  usually  indicates  a  fresh  focus  of 
infection,  an  extension  of  the  process,  suppuration,  or  the  devel- 
opment of  new  generations  of  micro-organisms.  A  subsidence 
of  the  leukocytosis  indicates  a  spontaneous  cure  or  a  localization 
of  the  process.  If  the  septic  process  is  strictly  limited,  there  may 
be  no  overplus  of  leukocytes  at  all.  In  a  large  abscess  in  the  para- 
vesical connective  tissue  between  the  uterus  and  bladder  four  weeks 
after  labor  there  was  less  than  the  normal  number  of  white  blood- 
corpuscles.  It  should  be  remembered  that  leukocytosis  docs  not 
necessarily  mean  suppuration.  It  may  be  absent  in  cases  of  ab- 
scess; it  may  be  most  marked  in  streptococcic  infection  of  the 
lymph-channels  without  suppuration.  In  addition  to  the  leukocy- 
tosis, the  blood  in  the  puerperal  sepsis  shows  degenerative  changes 
in  all  its  corpuscular  elements. 


730 


PATHOLOGY  OF   THE   PUERPERIUM. 


The  differential  count  of  the  leukocytes  is  helpful.  A  high  per- 
centage of  polymorphonuclear  cells  is  usually  indicative  of  suppura- 
tion. 

Any  elevation  of  temperature  after  delivery  calls  for  the  most 
careful  investigation.  A  vaginal  examination  should  be  made, 
both  digitally  and  with  the  speculum,  to  detect  the  following  con- 
ditions :  Redness  of  the  mucous  membrane  and  edema  of  the 
vulva  ;  false  membranes  and  ulceration  in  the  vagina  ;  arrested 
involution  and  fixation  of  the  uterus  ;    bogginess  and   extreme 


Fig-  551- — Doderlein's  lochial  tube  :  n,  Lochial  tube  within  its  test-tube  ;  h,  tube 
with  syringe  attached  ;  c,  tube  sealed,  for  transportation  to  laboratory.  The  cervix 
is  exposed  by  a  Sims  speculum,  is  pulled  down  by  a  tenaculum,  and  wiped  off  with 
bichlorid  solution  on  pledgets  of  cotton.  The  implements  and  operator's  hands  must 
be  aseptic. 


tenderness  of  the  uterine  walls  ;  enlargement  of  the  tubes  ;  en- 
largement, fixation,  or  displacement  of  the  ovaries  ;  edema  or 
exudate  in  the  pelvic  connective   tissue,  a;nd    thromboses  in  the 


PUERPERAL    SEPSIS. 


731 


pelvic  veins.  The  abdomen  should  be  carefully  palpated  for 
tenderness  and  exudate  ;  the  character  and  odor  of  the  lochia 
must  be  observed.  A  leukocyte  and  a  differential  count  should  be 
made.  The  blood  should  be  examined  for  the  Widal  reaction 
and  for  the  protozoa  of  malaria.  There  are  two  methods  of  pre- 
cision in  the  diagnosis  of  puerperal  sepsis  which  ought  always  to 
be  employed  if  possible  in  doubtful  cases:  intra-uterine  and  blood 
cultures.  The  first  is  based  on  the  assumption  that  the  uterine  cavity 
is  sterile  in  the  normal  case;  if  pathogenic  bacteria  are  discovered 
in  the  lochia  withdrawn  by  Doderlein's  tube  or  one  of  its  modifi- 
cations, the  patient  is  infected ;  if  the  cultures  from  the  uterine  cavity 


Fig.  552. — Nicholson's  modification  of  the  Doderlein  tube. 


are  sterile,  it  is  assumed  that  the  patient  is  not  infected,  though  she 
has  fever  and  other  symptoms  usually  due  to  sepsis.  Unfortunately 
this  method  is  not  invariably  rehable.  From  30  to  80  per  cent,  of 
afebrile  cases  show  a  positive  result  from  intra-uterine  cultures, 
the  percentage  increasing  as  the  puerperium  advances,^  and  in  a 
series  of  9  cases  of  streptococcic  infection  in  the  University  Matern- 
ity there  was  a  negative  result  in  4  cases  by  cultures  from  the  uterine 
lochia.  The  more  careful  the  technique,  to  avoid  contamination 
of  the  lochia,  the  more  accurate  is  the  diagnosis  by  this  method, 
but  with  the  very  best  technique  it  may  be  inaccurate  and  cannot 

1  Brownlee,  "  The  Germ  Content  of  the  Uterus  and  Vatjina  during  tlie  Nnrnial 
Puerperium,"  "Journal  of  Obstet.  anddyn.  ofllic  Br.  I'.nipire,"  September,  1905  ; 
Little,  "The  Bacteriology  of  the  Puerperal  Uterus,''  "Am.  journ.  of  Obstet.,"  Dec, 
1905. 


732  PATHOLOGY  OF   THE   PUERPERIUM. 

be  depended  upon.  Cultures  from  the  blood-serum  are  more 
reliable.  In  a  series  of  35  cases  in  the  University  Maternity  this 
method  did  not  fail  us  once  as  a  means  of  precision  in  diagnosis.^ 

Although  the  attempt  to  study  the  bacteriology  of  the  blood  in  cases  of  infection 
was  begun  many  years  ago  it  is  only  in  the  last  three  or  four  years  that  the  method 
has  become  satisfactory  as  a  means  of  precision  in  diagnosis.  Atliist  a  drop  of  blood 
was  taken  from  the  ear  and  smears  made  upon  solid  culture  media.  Recently  the 
bactericidal  property  of  the  blood  has  been  recognized;  it  is  now  realized  that  consid- 
erable quantities  of  blood  serum  must  be  procured,  that  it  must  be  well  diluted  in  the 
culture  media  and  that  the  technique  of  the  investigation  must  be  as  perfect  as  possi- 
ble to  obtain  satisfactory  results.  Dr.  J.  S.  Evans,  of  the  Pepper  Laboratory  of  the 
University  of  Pennsylvania,  employs  the  following  method  :  A  glass  Luer  syringe 
with  a  platino-iridium  needle,  holding  lo  c.c,  is  wrapped  in  raw  cotton,  enclosed  in 
filter  paper,  sealed,  and  is  sterilized  by  hot  air  at  a  temperature  of  150°  Cent,  for 
one  hour.  The  patient's  arm  is  prepared  as  for  an  operation  above  and  below  the  flex- 
ure of  the  elbow ;  is  washed  with  tincture  of  green  soap,  hot  water,  and  pledgets  of 
sterile  cotton;  then  with  alcohol;  a  wet  bichloride  of  mercury  dressing  is  applied  for 
ten  minutes;  the  skin  is  then  washed  off  with  sterile  water  and  a  dry  sterile  dressing 
applied  until  the  time  for  withdrawal  pf  the  blood.  The  operator  wears  sterile  rubber 
gloves.  Pressure  is  applied  above  the  elbow.  The  platino-iridium  needle  attached  to 
the  syringe  is  flamed,  and  plunged  into  the  most  prominent  vein.  Ten  c.c.  of  blood 
are  withdrawn.  The  needle  is  detached  from  the  syringe  to  lessen  the  risk  of  con- 
tamination. I  c.c.  of  blood  is  injected  from  the  syringe  into  five  flasks  of  bouillon, 
each  containing  150  c  c.  The  flasks  are  thoroughly  agitated.  Three  c.c.  of  blood  are 
distributed  among  6  tubes  of  litmus  milk.  The  remaining  2  c.c.  of  blood  are  discarded, 
as  it  is  the  first  quantity  withdrawn  and  the  most  likely  to  be  contaminated.  The  lit- 
mus milk  tubes  are  for  anaerobic  cultures  which  are  made  by  the  pyrogallic  acid  and 
the  sodium  dioxide  method.  All  the  flasks  areincubaied  at  37. 5°  C.  At  the  end 
of  twenty-four  hours,  the  flasks  are  examined  and  sub-cultures  are  made  on  slanted 
agar  and  glycerine  agar.  At  the  end  of  the  next  twenty-four  hour^,  if  the  cultures 
are  positive,  growth  has  occurred  on  the  so  id  media.  If  no  growth  has  occurred,  the 
flasks  are  kept  at  incubator  temperature  for  a  week  and  sub-cultures  are  made  daily. 
In  taking  the  uterine  lochia  for  cultures  the  implements  (a  Sims'  speculum,  a  single 
tenaculum,  dressing  forceps,  cotton,  and  Nicholson's  tube)  must  be  sterile.  The 
vulva  must  be  cleansed,  the  operator  must  wear  sterile  rubber  gloves,  and  the  cervix 
must  be  exposed  so  that  the  tube  may  be  inserted  without  risk  of  contamination. 
After  inserting  the  protecting  metal  sheath,  the  glass  tube  within  it  is  pushed  further 
into  the  uterine  cavity,  opening  the  metal  shutter  on  the  end  of  the  former.  The 
lochia  is  drawn  into  the  glass  tube  by  suction.  The  glass  tube  is  then  withdrawn 
into  the  metal  sheath  ;  the  two  together  are  then  withdrawn  and  both  ends  of  the 
class  tube  are  sealed  by  heat.  The  sealed  tube  is  sent  to  the  bacteriological  labora- 
tory for  investigation. 

Unfortunately,  both  these  methods  demand  the  skill  and  train- 
ing of  an  e.xpert.  Any  imperfection  of  technique  vitiates  the  results 
and  makes  the  examination  worse  than  useless,  as  it  may  lead  to 
serious  errors  in  diagnosis. 

Preventive  Treatment  of  Puerperal  Sepsis. — It  is  convenient 
to  deal  separately  with  the  several  sources  of  puerperal  infection 
in  describing  the  preventive  treatment. 

Atmosphere. — While  the  air  is  not  so  frequent  a  source  of 
infection  as  it  was  thought  to  be  in  the  beginning  of  the  anti- 

ip.  C.  Hirst,  "  Some  Problems  in  the  Diagnosis  and  Treatment  of  Puerperal  In- 
fection," "Am.  Medicine,"  Jan.  27,  igo6  ;  W.  R.  Nicholson  and  J.  T.Evans,  "The 
Bacteriology  of  the  Puerperal  Uterus,"  ".Am.  Jour.  Med.  Sci.,"  August,  igcS. 


PUERPERAL   SEPSIS.  733 

septic  era,  it  is  undeniable  that  an  atmosphere  whicli  is  stag- 
nant, deprived  of  sunhght,  impregnated  with  dust,  tainted  with 
foul  odors  and  mephitic  gases,  may  not  only  contain  disease 
germs  and  spores  in  larger  proportion  than  it  should,  but  also 
has  a  most  depressing  effect  upon  an  individual  subjected  to  its 
influences,  reducing  the  vitality  and  resisting  power  of  the  body 
cells  until  there  occurs,  perhaps,  microbic  invasion  of  the 
system  that  would  have  been  successfully  resisted  had  the 
organism  preserved  its  normal  combative  power  against  patho- 
genic bacteria.  The  lying-in  room,  therefore,  should  be  sunny  ; 
should  be  well  ventilated — best  by  an  open  fire-place  ;  and  it 
should  not  possess  a  stationary  wash-stand  or  any  other  connec- 
tion with  the  sewer  ;  nor  should  it  be  too  near  the  bath-room 
and  water-closet.  If  there  is  a  stationary  wash-stand  in  the  room, 
its  outlet  should  be  kept  stopped,  water  should  be  allowed  to 
stand  in  it,  and  the  overflow  holes  should  be  plugged  with  small 
corks  or  putty.  If  the  bath-room  immediately  adjoins  the 
lying-in  room,  the  door  between  should  be  stripped. 

If  the  room  is  heated  by  a  hot-air  furnace,  the  intake  for  the 
air  and  the  sanitary  condition  of  the  cellar  may  need  investiga- 
tion. The  nurse  should  be  cautioned  not  to  leave  trays  of  food, 
an  unemptied  bed-pan,  or  a  commode  in  the  room  over  night  or 
for  any  length  of  time.  An  antiseptic  vulvar  pad  should  be 
worn  during  the  continuance  of  the  lochial  discharge,  so  as  to 
protect  the  genital  orifice  from  contact  with  the  atmosphere,  and 
the  materials  of  which  this  pad  is  composed,  or,  rather,  the  anti- 
septics with  which  it  is  impregnated,  should  be  chosen  with  a 
view  of  keeping  the  bloody  discharge  from  decomposing,  should 
it  soak  through  the  pad,  and  thus  be  exposed  to  atmospheric 
contamination.  The  best  materials  for  this  purpose,  in  my  ex- 
perience, are  salicylated  cotton  and  carbolized  gauze. 

Water. — The  water  used  for  douches,  if  they  are  employed, 
or  for  washing  the  vulva  and  perineum,  may  be  the  source 
of  fatal  infection.  All  the  water  used  about  the  puerpera  should 
be  boiled  beforehand  for  at  least  half  an  hour.  It  is  not  suffi- 
cient to  make  a  germicidal  solution — as,  for  example,  of  corrosive 
sublimate — in  the  belief  that  all  germs  in  the  water  are  killed  by 
the  antiseptic  employed.  Tetanus  bacilli  will  live  for  hours  in  a 
I  :  4000  bichlorid  of  mercury  solution,  and  the  other  antiseptics 
usually  employed  in  obstetric  practice — lysol,  kresin,  creolin — 
may  be  perfectly  inert  against  many  dangerous  pathogenic  germs 
during  the  time  that  usually  intervenes  between  the  preparation 
of  antiseptic  solution  and  its  use  upon  a  patient.  Three  women 
in  the  University  jNIatcrnily  contracted  tetanus  from  intra-utcrine 
douches  of  unboiled  water  (creolin,  two  per  cent.),  during  a  time 


734  PATHOLOGY   OF   THE   PUERPEKIUM. 

when  the  water  of  Philadelphia  was  unusually  turbid,  in  con- 
sequence of  freshets  in  the  Schuylkill  Valley. 

It  is  possible  that  the  patient's  vagina  might  be  infected  in  the 
full  bath  taken  before  labor  begins  if  she  sits  or  lies  in  the  tub  full 
of  water  which  may  be  contaminated  by  the  rinsings  from  her  body, 
A  sponge  or  douche  bath  in  the  erect  posture  is  safest. 

The  Patient. — The  parturient  and  puerperal  woman  may  be 
infected  by  disease  germs  carried  upon  her  person,  especially  in 
the  pubic  and  anal  regions  ;  by  her  personal  clothing,  by  the 
bed-clothing  and  mattress,  by  the  vulvar  pads  and  the  pads  upon 
which  the  buttocks  rest,  by  the  material  used  to  wash  the  vulva 
and  perineum,  and  by  pathogenic  bacteria  lodged  in  the  vaginal 
or  uterine  mucous  membranes  before  labor  or  even  prior  to  con- 
ception. 

To  insure  the  greatest  obtainable  degree  of  personal  cleanli- 
ness, the  woman  falling  in  labor  should  be  given  a  full  bath, 
special  attention  being  paid  to  scrubbing  the  genital  region  most 
thoroughly  with  soap,  hot  water,  and  a  soft,  bristle  brush  or  a 
wash-rag.  In  hospital  practice  my  patients  are  shaved.  In 
private  practice  this  is  also  done  if  the  patient  permits  it.  Some- 
times a  depilatory  is  allowed  if  shaving  is  not  permitted.  After 
the  bath,  the  woman  should  put  on  clean  clothes  throughout. 
The  mattress  on  her  bed  should  not  be  soiled  by  the  discharges 
of  previous  labors,  by  urine,  feces,  or  other  putrescible  matter. 
It  should  not  have  been  used  in  any  case  of  contagious  or  infectious 
disease,  and  it  should  be  protected  by  a  rubber  cloth  that  has  been 
carefully  scrubbed  clean.  The  bed-clothing  should  be  clean,  the 
bed  being  freshly  made  up  for  the  labor.  The  pads  on  which  the 
buttocks  rest  during  labor  and  afterward  should  be  made  of  nursery 
cloth  prepared  in  the  way  described  in  the  directions  to  the  nm^se 
(boiled  and  dried).  It  is  scarcely  necessary  to  say  that  a  pad  when 
soiled  should  be  thrown  away  and  not  used  again.  The  vulvar 
pads  should  be  made  of  carbolized  gauze  and  sahcylated  cotton — 
the  best  materials  for  disinfecting  a  bloody  discharge.  The  nurse 
should  make  them  up  with  sterile  hands  as  they  are  required,  or 
if  she  makes  a  number  at  a  time  they -should  be  wrapped  in  a 
clean  towel  and  taken  out  for  use  with  sterile  hands.  The 
material  used  to  wipe  off  the  genital  orifice,  the  mouth  of  the 
urethra,  and  the  perineum  should  be  absorbent  cotton  sterilized 
by  heat  or  by  soaking  in  a  i :  looo  solution  of  sublimate  for  at 
least  one-half  hour  before  use.  During  the  second  stage  of  labor 
these  pledgets  of  cotton  are  employed  to  wipe  away  feces  as  it 
emerges  from  the  anus,  always  in  the  direction  from  before  back- 
ward. 

Care   must   be   exercised    to    remove   blood    and    blood-clots 


PUERPERAL   SEPSIS.  735 

from  the  vulva  before  putrefaction  sets  in.  This  is  best  done  by 
placing  the  woman  on  a  bed-pan,  letting  a  stream  of  boiled 
water  run  over  the  parts,  and,  if  necessary,  using  cotton  to  wipe 
them  off.  This  should  be  done  about  six  times  in  the  twenty- 
four  hours  for  the  first  four  or  five  days. 

A  careful  examination  should  be  made  of  every  woman's 
vaginal  discharges  in  the  beginning  of  labor.  If  there  is  leukor- 
rhea,  or  any  pathological  condition  of  the  vaginal  secretions,  the 
vagina  should  be  thoroughly  scrubbed  with  tincture  of  green 
soap,  hot  water,  and  pledgets  of  cotton,  and  should  then  be 
douched  with  a  bichlorid  of  mercury  solution,  i  :  2000,  a  little 
clear  water  being  employed  at  the  end  of  the  douche  to  wash 
out  any  residual  sublimate  solution  that  might  poison  the 
patient  or  do  harm  to  the  infant's  eyes  in  its  descent  through  the 
birth-canal. 

It  should  be  borne  in  mind,  in  the  conduct  of  the  labor,  that 
excessive  bruising,  long-continued  pressure  of  the  maternal 
tissues,  and  extensive  injuries,  all  conduce  to  microbic  invasion  of 
the  parts  by  reducing  their  vitality  and  by  affording,  through  solu- 
tions of  continuity,  a  ready  entrance  into  the  system.  The  proper 
conduct  of  labor,  therefore,  is  an  extremely  important  item  in  the 
preventive  treatment  of  puerperal  sepsis. 

Finally,  in  the  management  of  the  third  stage  of  labor  and 
of  the  early  puerperium,  the  greatest  care  should  be  exercised  to 
evacuate  the  uterine  cavity  of  all  putrescible  matter  and  to  secure, 
as  far  as  possible,  firm  contraction  of  the  womb,  for  the  presence 
of  putrescible  material  within  the  uterine  cavity  attracts  sapro- 
phytes, and  an  imperfect  involution  of  the  womb  favors  the  direct 
invasion  of  the  uterine  sinuses  and  blood-channels  by  micro- 
organisms and  the  absorption  of  the  products  of  microbic  activity 
into  the  circulation  and  into  the  lymph-spaces. 

The  Physician. — The  physician  should  not  carry  infectious 
germs  upon  his  person  or  clothing  into  the  lying-in  chamber, 
and  he  should  be  scrupulously  careful  not  to  insert  pathogenic 
germs  into  the  woman's  vagina  in  the  course  of  his  examinations. 
If  a  general  practitioner  is  in  attendance  upon  infectious  and  conta- 
gious diseases,  he  should  either  give  up  obstetric  practice  entirely, 
or,  if  he  can  not  do  so,  he  should  take  a  full  bath  and  should 
change  his  clothing  completely  before  attending  a  woman  in  labor. 

A  long  linen  gown  or  duck  trousers  and  a  cheviot  shirt 
should  be  carried  in  the  obstetric  bag.  The  change  of  clothing 
should  be  made  in  another  room  before  seeing  the  patient  at  all, 
or,  at  any  rate,  before  making  an  examination. 

The  methods  of  hand  cleansing  are  described  in  the  section  on 
Aseptic   Technicjue.     The   routine    use   of   sterile   rubber   glo\-cs 


736  PATHOLOGY   OF   THE   PUERPERIUM. 

in  addition  to  the  hand  disinfection  is  an  indispensable  precau- 
tion. If  version  or  any  manoeuver  is  attempted  involving  the 
deep  insertion  of  the  hand  into  the  uterine  cavity,  the  long  gaunt- 
let glove,  reaching  to  the  elbow,  should  always  be  worn.  The 
examining  finger  should  be  anointed  with  carbolized  vaselin  (5 
per  cent.)  or  the  sterile  unguent  provided  in  collapsible  tubes, 
and  in  making  the  examination  the  vulvar  orifice  should  be  ex- 
posed by  raising  the  upper  buttock  as  the  woman  lies  upon  her 
side,  so  that  the  finger  may  be  inserted  directly  into  the  vagina 
without  becoming  contaminated  by  being  swept  over  the  skin  near 
the  anus  or  pubes  while  searching  for  the  vulvar  orifice.  Before 
inserting  the  finger,  the  skiii  around  the  vaginal  entrance  should  be 
wiped  off  with  a  pledget  of  cotton  soaked  in  a  i :  2000  sublimate 
solution.  As  every  examination  entails  some  risk  of  infection,^  they 
should  be  as  limited  in  number  as  possible.  The  best  results  in 
morbidity  and  mortality  have  been  secured  by  an  almost  entire 
elimination  of  the  vaginal  examination,  which  has  been  replaced, 
in  the  practice  of  some  enthusiasts,  by  abdominal  palpation,  and 
even  by  rectal  examinations.  It  is  unnecessary,  however,  and 
is,  moreover,  inadvisable  to  give  up  the  vaginal  examination  al- 
together. Much  may  be  learned  by  abdominal  palpation,  so 
that  there  is  little  necessary  information  to  be  gained  by  examin- 
ing per  vaginam,  but  there  are  some  conditions  that  can  be  learned 
in  no  other  way.  A  few  vaginal  examinations  in  the  course  of 
labor  are  therefore  indispensable.  No  harm  is  done  if  their  num- 
ber is  restricted,  if  the  examining  hand  is  protected  by  a  sterile 
glove,  and  if  the  examination  is  conducted  in  the  way  just  de- 
scribed. 

The  Nurse. — The  nurse  should  adopt  the  same  precautions 
in  regard  to  personal  cleanliness  that  have  been  recommended 
for  the  physician.  She  should  not  have  come  from  a  contagious 
or  infectious  case.  She  should  put  on  fresh  clothing  throughout 
for  attendance  upon  the  obstetrical  patient.  She  must  take  a 
full  bath,  scrubbing  her  hair  and  scalp  well  with  soap  and  w^ater, 
and  rinsing  her  hair  in  a  i  :  1000  sublimate  solution.  She  should 
cleanse  her  hands  and  put  on  sterile  rubber  gloves  before  attempt- 
ing any  manipulation  of  a  patient's  genital  region  or  of  her  breasts. 
It  is  her  duty  also,  in  the  care  of  a  puerpera,  to  enforce  the  sanitary 
and  aseptic  regulations  already  described  under  their  appropriate 
heads. 

The  Implements. — All  implements  to  be  used  about  the  person 
of  the  parturient  and  puerperal  woman  should  be  boiled  for  at 
least  five  minutes.  A  i  :  1000  sublimate  solution  should  be 
employed  for  the  disinfection  of  the  few  articles  that  might 
be    injured    by  boiling  water,   a  full    half   hour   at   least   being 


PUERPERAL    SEPSIS. 


737 


allowed  for  the  immersion,  and  the  bichlorid  solution  being  made 
up  with  boiled  water. 


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Fig.  553. — Temperature-chart  of  a  case  treated  in  vain  by  intia-uterine  irrigation,  but 
cured  immediately  by  the  instrumental  evacuation  of  the  uterus. 

The  Curative  Treatment  of  Puerperal  Infection. — The  treat- 
ment of  puerperal  sepsis  is  both  local  and  general.  Locally,  a 
thorough  disinfection  of  the  whole  genital  canal  is  called  for  in 
every  case  of  puerperal  infection.  It  may  appear  unnecessary, 
and  may  prove,  on  actual  experience,  to  be  even  harmful,  but  no 
one  can  tell  beforehand  how  necessary  this  procedure  is.  In  the 
vast  majority  of  cases  it  is  productive  of  the  greatest  good.  It  is 
only  occasionally  useless,  and  very  rarely  actually  harmful.  It 
should,  as  already  stated,  precede  all  other  treatment  for  puerperal 
infection.  The  method  of  disinfecting  the  genital  canal  may  be 
described  as  follows:  A  double  tenaculum,  a  large,  dull  curet, 
a  placental  forceps  (Emmet's  curetment  forceps  is  the  best), 
and  an  intra-v.terine  catheter  are  boiled  for  fifteen  minutes. 
The  operator  disinfects  his  hands  and  arms  and  wears  sterile 
gloves.  The  patient  is  placed  in  the  dorsal  posture  across  the 
bed,  with  her  buttocks  resting  on  a  rubber  pad.  The  external 
genitalia  and  the  vagina  are  scmbbcd  with  tincture  of  green  soap 
and  pledgets  of  cotton;  the  vagina  is  douched  with  a  sublimate 
solution,  1 :  2000.  The  operator  then  seizes  the  anterior  lip  of 
the  cervix  with  the  tenaculum.  An  intra-uterine  douche  of  sterile 
water,  at  least  a  quart,  is  administered.  Then,  with  the  placental 
forceps,  and,  if  necessary,  with  a  dull  curet,  the  uterine  walls  are  gone 
o\'er  thoroughly  but  lightly  in  all  directions,  six  to  twelve  times, 
until  nothing  is  brought  away  but  bright  blood.  A  second  intra- 
uterine douche  concludes  the  treatment.  If  the  womb  is  flabby 
and  large,  with  a  tendency  to  flexion,  so  that  the  drainage  of  the 
47 


738  PATHOLOGY  OF   THE   PUERPERIUM. 

uterine  cavity  is  not  good,  it  is  advisable  to  pack  it  with  iodoform  or 
sterile  gauze. 

Much  discredit  has  attached  to  this  method  of  instrumental 
evacuation  of  an  infected  uterus  because  it  has  too  frequently 
been  carried  out  like  a  curettage  of  a  non-puerperal  uterus,  which 
would  often  result  in  implanting  infection  in  the  myometrium  or 
in  perforating  the  uterus. 

In  addition  to  cleansing  the  uterine  cavity  in  the  manner 
described,  the  operator  should  take  the  opportunity  of  carefully 
inspecting  the  visible  portion  of  the  parturient  tract ;  and  if 
there  are  false  membranes  or  areas  of  inflammation  and  localized 
infection  on  the  cervix  or  in  the  vagina,  they  should  be  carefully 
treated — best  by  the  application  of  a  strong  solution  of  nitrate 
of  silver,  a  dram  to  the  ounce. 

It  may  be  necessary  to  repeat  the  intra-uterine  douches  several 
times — in  fact,  several  times  a  day  for  many  days  ;  in  this  case 
plain  sterile  water  only  should  be  used.  Nothing  is  gained  by  the 
employment  of  strong  sublimate  solutions,  which  can  not  always 
reach  and  destroy  the  infecting  micro-organisms  of  the  genital 
tract,  but  which  do  have  a  most  depressing  action  upon  the  body- 
cells  of  the  walls  of  that  tract,  reducing  their  resisting  power  against 
the  invasion  of  attacking  bacteria,  and  which  may  fatally  poison 
the  patient.  The  author  has  employed  a  one  per  cent,  formalin 
solution  in  glycerin  and  water,  tincture  of  iodin,  i  dr.  to  a  pint  each  of 
water  and  alcohol,  and  a  five  per  cent,  argyrol  solution  as  intra- 
uterine douches  with  better  results  than  are  obtained  by  sublimate 
solutions. 

It  is  rarely  necessary  to  repeat  the  instrumental  evacuation 
of  the  uterus.  It  may  be  advisable  to  provide  drainage  from  the 
uterine  cavity  by  the  insertion  of  a  strip  of  gauze  to  the  fundus. 
This  is  only  necessary,  however,  in  cases  of  flabby,  relaxed 
wombs  which  are  so  sharply' anteflexed  as  to  prevent  the  free  exit 
of  the  lochial  discharge. 

The  general  treatment  is  stimulating.  The  patient  should 
have  as  much  food  of  an  easily  digestible  character,  chiefly  milk, 
as  she  can  assimilate,  and  as  much  alcohol  as  she  can  consume 
without  showing  the  physiological  effects  of  it.  Digitalis  is 
useful  as  long  as  the  pulse  is  above  no.  Strychnin  may  be 
combined  with  it  in  suitable  cases.  To  tide  the  patient  over 
emergencies,  carbonate  of  ammonia  in  large  doses,  by  the  bowel, 
and  nitroglycerin  hypodermatically,  may  be  required.  Inhala- 
tions of  oxygen  may  also  be  of  service.  Absolute  rest  and 
freedom  from  all  disturbances,  mental  and  physical,  must  be 
insisted  upon,  and  the  patient  should  be  given  the  best  nursing 
that  the  family  can  afford. 


PUERPERAL    SEPSIS.  739 

The  Serum=therapy  of  Puerperal  Sepsis. — Stimulated  by  the 
success  of  this  treatment  in  diphtheria  and  in  other  infectious  dis- 
eases, an  effort  has  been  made  to  procure  a  serum  that  is  antago- 
nistic to  streptococci  and  antidotal  to  the  products  of  their  activity. 

A  committee  appointed  by  the  American  Gynecological  Society^ 
reported  in  May,  1899,  that  352  cases  had  been  treated  by  anti- 
streptococcic serum,  with  a  mortality  of  20.74  per  cent.  After  a 
personal  trial  of  the  method  extending  over  three  years  I  discarded 
it,  but  have  lately  resumed  its  use,  as  it  undeniably  is  followed 
occasionally  by  decided  and  sometimes  by  brilliant  results.  From 
20  to  80  c.c.  are  injected  once  to  four  times  a  day.  Further 
studies  of  the  anti-streptococcic  serum,  as  to  its  bacteriolytic 
power,  agglutinating  activity  and  as  a  stimulating  agent  for  the 
production  of  opsonins,  with  improvements  in  its  production 
suggested  by  this  investigation,  promise  a  remedy  in  the  future 
of  great  use. 

The  Bacterin  Treatment  of  Septic  Infection. — As  a  result  of 
the  disco\:eries  of  Wright  and  others  of  the  increased  opsonic 
index  produced  by  the  injection  of  dead  and  sterilized  micro- 
organisms of  the  kind  which  caused  the  infection,  the  injection  of 
streptococcic,  staphylococcic,  gonococcic,  and  tubercular  bacterins 
is  securing  a  trial  in  puerperal  infections.  In  one  of  my  cases  of 
severe  and  long- continued  streptococcic  infection  which  had  resisted 
all  other  treatment,  an  injection  of  two  and  a  half  million  strepto- 
cocci was  followed  immediately  by  a  permanent  disappearance  of 
all  symptoms.- 

The  Treatment  of  Septic  Infection  by  the  Artificial  Production  of  a 
Hyperleukocytosis. — Phagocytosis  has  been  demonstrated  to  be  par- 
ticularly effective  in  destroying  streptococci,  if  the  blood  serum 
is  rich  in  opsonins,  the  mere  overplus  of  leukocytes  not  being 
sufficient  unless  the  bacteria  are  opsonatcd.  It  is  logical  there- 
fore to  stimulate  the  production  of  leukocytes  if  at  the  same 
time  measures  are  taken  to  increase  the  opsonins  of  the  blood. 
Antistreptococcic  serum  does  the  latter  to  some  extent,  it  is  claimed.^ 
So  do  the  bacterins.  Several  agents  have  leukocytic  powers,  not- 
ably pilocarpin,  albumose,  and  nuclein.  The  last  is  the  best 
remedy  in  septic  infection.  Ten  to  sixty  n-.inim.s  of  nuclein  solu- 
tion should  be  given  hypoderm_ically  three  tim_es  a  day. 

Hofbauer,'  from  Schauta's  clinic  in  Vienna,  reported  the  results 
of  employing  Horbaczewski's  nuclein  in  seven  cases  of  puerperal 

1  "Am.  Jour,  of  Ob.stet.,"  vol.  .xl,  No.  3,  1899. 

■^  "  Tile  Opsonic  Treatment  of  Disease,"  Illnian  and  Duncan,  "  N.  V.  Med. 
Journ.,'  June  27,  1908. 

•'  "  l'haf;<icytosis  and  Opsonins,"'  Ludvit;  lieklnen,  "Jiiur.  Am.  Med.  Assoc.,'' 
May  12,  igo6. 

■*  "  Centralbl.  f.  Gyn.,"  No.  17,  1896,  p.  441. 


740  PATHOLOGY  OF   THE   PUERPERIUM. 

infection,  and  in  a  later  report  adds  t\Yelve  more  to  the  list.^  The 
cures  effected  in  some  of  these  cases  certainly  warrant  a  further 
trial  of  the  method.  For  some  years  I  have  administered  nuclein 
routinely  as  a  part  of  the  treatment  of  puerperal  sepsis. 

A  peculiar  method  of  increasing  the  polynuclear  cells  has  been  proposed  in 
France  :  horse  serum  is  heated  every  two  hours  for  three  days  to  56°  C.  Some  of 
the  serum  is  dried  by  evaporation.  The  uterine  cavity,  previously  cleansed  and 
dried,  is  tamponed  with  ^auze  saturated  with  the  serum  and  containing  besides  1-3 
gr.  of  the  dried  serum.     The  tampon  is  changed  in  twenty  hours.^ 

The  Treatment  of  Sepsis  by  Washing  the  Blood  ;  Hypodermatocly= 
sis;  Intravenous  Injections  cf  Saline  Solutions,^  is  a  modern  treat- 
ment attended  with  decided  success.  The  best  fluid  for  the 
purpose  is  I  ^  gr.  CaCl,  1 1  5^  gr.  KCl,  to  34  oz.  normal  salt 
solution.  4  Injections  of  large  amounts- — more  than  two  quarts — 
of  this  fluid  into  the  bowel  seem  to  give  as  good  results  as 
hypodermatoclysis,  and  are  rnuch  more  convenient.  The  use  of 
the  modified  normal  salt  solution  is  a  valuable  adjuvant  to  the 
other  measures  required  in  the  treatment  of  puerperal  sepsis. 

Colloidal  Silver  (protargol,  collargol,  argyrol) — by  inunction 
(Crede's  ointrnxcnt),  by  intravenous  injections  (3-5  cm.  2  per  cent, 
solution  of  collargol  repeated  three  to  four  times),  by  rectal  injections 
— has  its  advocates.  It  has  secured  extensive  cHnical  trials  in 
Chrobak's  Clinic,  in  the  Charite  in  Berlin,  in  Buda-Pesth,  and  in 
other  large  maternities.  The  verdict,  on  the  whole,  is  favorable. 
As  an  adjunct  to  other  treatment  it  may  be  recommended.^ 

The  Operative  Treatment  of  Sepsis  in  the  Child=bearing  Period. — ■ 
Since  the  first  performance  by  Tait  of  abdominal  section  for  puru- 
lent peritonitis  there  has  been  an  extremely  important  develop- 
ment, in  the  scope  of  pelvic  and  abdominal  surgery  for  septic  in- 
flammations during  the  child-bearing  period. 

Regarded  at  first  as  a  procedure  analogous  to  opening  an 
abscess  anywhere  on  the  body,  the  whole  abdominal  cavity  being 
looked  upon  as  an  abscess-cavity  and  the  abdominal  walls  as 
its  capsule,  abdominal  section  for  puerperal  sepsis  has  become 
a  generic  term  of  wide  significance,  including  hysterectomy, 
salpingo-oophorectomy,  evacuation  of  abscesses  in  the  peritoneal 
cavity  and  in  the  pelvic  connective  tissue,  removal  of  gangrenous 

1  "Arch,  f  Gyn.,"  Bd.  Ixvii,  H.  2. 

^  "  Bull.  Soc.  d'Obstet.  de  Paris,"  Tome  ix,  1906. 

^  Bose,  "  Presse  medicale,"'  No.  49,  1896. 

■*  See  experiments  of  W.  H.  Howell,  in  Boston,  on  frog's  heart ;  modified  Ringer 
fluid.  "  Tiie  Use  of  Intravenous  Saline  Injections  for  the  Purpose  of  ^\'ashing  the 
Blood,"  II.  A.  Hare,  "Therapeutic  Gazette,''  April  15,  1897.  The  technic  of  the 
injection  is  the  same  as  for  the  injections  required  in  the  treatment  of  the  acute 
anemia  following  severe  hemorrhage. 

5"Wien.  Klin.  Wochenschr.,"  No.  10,  1906;  "Med.  Klinick,"  p.  816,  Nos. 
31-34,  1906. 


PUERPERAL   SEPSIS.  J A,l 

or  infected  neoplasms  of  or  in  the  neighborhood  of  the  parturient 
tract,  and  exploratory  incisions. 

Indications  for  Ahdominal  Section  in  the  Treatment  of  Puer- 
peral Sepsis. — It  is  more  con\enient  to  deal  generically  with  the 
indications  for  abdominal  section  in  the  course  of  puerperal  sepsis, 
for  the  operation  is  usually  decided  upon  in  practice  without  refer- 
ence to  what  may  be  required  after  the  abdomen  is  opened,  the 
surgeon  holding  himself  in  readiness  to  perform  any  of  the  pelvic 
or  abdominal  operations  detailed  above  that  may  be  found  neces- 
sary when  the  abdominal  cavity  is  exposed  to  view  and  to  touch. 

In  order  to  decide  correctly  for  or  against  celiotomy  in  the  course 
of  puerperal  septic  fever,  the  medical  attendant  must  be  famihar 
with  the  different  forms  of  sepsis  after  labor,  and  should  know 
which  of  them  are  most  and  which  are  least  amenable  to  surgical 
treatment.  In  a  general  way,  it  may  be  stated  that  the  opera- 
tion is  demanded  most  frequently  for  localized  suppurative 
peritonitis  ;  it  may  be  indicated,  and  often  is,  for  diffuse  suppura- 
tive peritonitis  ;  for  suppurative  salpingitis  and  ovaritis  ;  for  sup- 
purative metritis,  if  the  inflammation  extends  outward  toward 
the  peritoneal  investment  of  the  womb  or  into  the  connective 
tissue  of  the  broad  ligament ;  for  abscesses  in  the  pelvic  con- 
nective tissue  ;  for  infected  abdominal  or  pelvic  tumors.  On  the 
contrary,  abdominal  section  is  contraindicated  or  is  not  required 
in  simple  sapremia  ;  in  septic  endometritis  of  all  forms — diph- 
theric, ^  ulcerative,  suppurative;  in  dissecting  metritis,  sloughing 
intra-uterine  myomata,  which  can  be  rem_oved  by  enucleation  or 
avulsion,  or  in  suppurative  m.etritis  with  the  abscess  pointing  into 
the  uterine  cavity;  in  phlebitis,  lymphangitis,  and  in  direct  infection 
of  the  blood-current.  One  is  most  likely  to  perform  an  unnecessary 
operation  in  streptococcic  endometritis.  By  the  time  that  symp- 
toms justify  surgical  intervention  in  this  condition  it  is  almost  always 
too  late. 

It  is  difficult  to  formulate  rules  in  a  situation  involving  so  much 
responsibility,  and  of  necessity  so  dependent  upon  many  circum- 
stances, as  that  seeming  to  require  a  very  serious  surgical  opera- 
tion in  the  midst  of  an  adynamic  fever  with,  very  likely,  profound 
depression,  rapid  pulse,  high  temperature — in  short,  with  every- 
thing a  surgeon  least  desires  in  the  face  of  a  major  operation. 

The  operative  treatment  of  puerperal  sepsis  should  be  avoided 
if  jjossible,  and  is  not  indicated  by  the  cardinal  symptoms  of  sc])tic 
infection — high  temj)erature,  rapid  pulse,  and  general  depression. 

1  By  diphtheric  endometritis  is  meant  a  dirty,  grayish-  or  greenish-brown 
exudate  on  the  endometrium,  containing  mixed  micro-organisms,  and  not  necessarily 
the  Klebs-Loffler  bacilkis.  For  a  report  of  one  and  the  mention  of  four  cases  of  true 
diphtheria  of  the  genitalia  see  Williams,  "  Amer.  Jour,  of  Obstet.,"  August,  1S98. 


742  PATHOLOGY  OF   THE   PUERPERIUM. 

There  should  be  some  demonstrable  evidence  of  intrapelvic  or 
abdominal  inflammation,  necrosis,  or  suppuration. 

On  the  first  appearance  of  symptoms  that  justify  the  diagnosis 
of  diffuse  suppurative  peritonitis,  the  abdomen  must  be  opened 
without  more  delay  than  is  necessary  for  an  aseptic  operation. 
Even  with  the  utmost  promptness  the  operation  is  almost  always 
too  late,  for  the  inflammation  extends  so  rapidly  and  at  first  insid- 
iously that  by  the  time  a  diagnosis  is  possible  the  progress  of  the 
disease  can  not  be  stayed.  It  must  be  admitted,  however,  that  an 
occasional  success  is  possible  by  timely  surgical  interference.^ 

Again,  in  the  presence  of  exudate,  adhesions,  or  unnatural 
enlargement  of  any  pelvic  structure,  suppuration  may  be  sus- 
pected if  the  physical  signs  do  not  improve  and  if  the  tempera- 
ture, pulse,  and  general  condition  indicate  a  continuance  of  septic 
inflammation.  It  is  hardly  necessary  to  state  that  if  pus  forms 
it  must  be  reached  and  evacuated  irrespective  of  its  situation. 
Just  how  long  to  wait,  however,  is  a  question  requiring  experi- 
ence, good  judgment,  and  a  special  study  of  each  individual  case 
for  its  correct  answer. 

Enormous  pelvic  and  abdominal  exudates  may  disappear  ; 
adhesions  may  melt  away  ;  enlarged  and  inflamed  tubes,  ovaries, 
and  uterus  may  resume  their  proper  size,  functions,  and  condition 
on  the  subsidence  of  the  inflammation  ;  but  in  these  favorable 
cases  distinct  signs  of  improvement  manifest  themselves  in  a  few 
days,  and  the  course  of  the  disease  is  comparatively  short.  A 
mere  protraction  of  septic  symptoms  is  in  itself  suspicious,  along 
ivitli  local  signs  of  inflaniniation.  Without  the  latter,  the  same 
general  symptoms,  sometimes  lasting  for  months,  indicate  phle- 
bitis and  infection  of  the  blood-current.  In  this  form  of  sepsis 
an  operation,  I  believe,  can  do  no  good  and  may  do  the  greatest 
harm. 

In  infected  tumors  in  and  near  the  genital  tract  the  indication 
for  operation  should  be  plain  and  the  decision  easy.  The  pres- 
ence of  the  tumor  should,  of  course,  be  known.  On  the  first  sign 
of  inflammation  in  it,  or  in  the  event  of  an  elevated  temperature 
for  which  there  is  no  good  explanation,  the  tumor  should  be 
removed.  Early  operations  in  these  cases  have  furnished  the 
best  results,  delayed  operations  the  reverse.'^  In  cystic  tumors 
the  likelihood  of  twisted  pedicle  should  be  remembered,  and  in 
every  case  of  child-birth  complicated  by  a  new  growth  the  woman 

1  Hirst,  "A  Diffuse,  Unlimited,  Suppurative  Peritonitis  in  a  Child-bearing 
Woman  Cured  by  Abdominal  Section,"  "Medical  News,"  1894. 

2  The  most  desperate  cases,  however,  need  not  be  despaired  of.  I  have  success- 
fully removed  a  gangrenous  ovarian  cyst  from  a  puerpera  who  was  so  weak  that 
complete  anesthesia  was  not  attempted.  The  late  Dr.  Goodell  had  declined  the 
operation  as  necessarily  fatal. 


PUERPERAL   SEPSIS.  743 

should   be  watched  with  extraordinary  care  to  detect  the  first 
indication  of  trouble. 

An  exploratory  abdominal  incision  should  be  made,  as  a  rule, 
only  when  it  is  desired  to  determine  if  a  pelvic  mass,  presumably 
containing  pus,  is  situated  within  or  without  the  peritoneal 
cavity,  and  if  the  abscess  had  better  be  evacuated  through  the 
abdominal  cavity  or  extraperitoneally.  In  the  early  period  of 
experimentation  with  abdominal  section  for  puerperal  sepsis 
exploratory  incisions  were  made  in  obscure  cases  without  local 
symptoms  of  inflammation  in  the  pelvis  or  the  abdomen.  None 
of  these  operations  yielded  information  of  value,  nor  did  they  bene- 
fit the  patients.  Consequently,  it  is  a  safe  rule  not  to  open  the 
abdomen  of  a  puerpera  for  sepsis  unless  there  are  physical  signs 
of  inflammation  in  the  abdomen  or  the  pelvis. 

The  proposition  of  Bumm,  v.  Bardeleben/  and  others,  to  ligate 
or  exsect  the  ovarian  veins  in  thrombophlebitis,  does  not  seem 
reasonable. 

Thrombophlebitis  is  a  conservative  action  to  limit  the  spread 
of  infection;  if  it  is  successful,  the  patient  recovers,  and  this  is 
the  usual  result.  If  the  thrombus  breaks  down  and  there  is  septic 
metastasis  (pyemia),  the  patient  will  probably  die,  even  if  the 
original  site  of  the  thrombus  is  removed.  If  the  thrombus  extends 
to  the  vena  cava,  the  case  is  also  hopeless.  Another  difficulty  is 
the  diagnosis.  I  know  of  no  way  by  which  a  thrombus  of  the 
ovarian  or  hypogastric  veins  can  be  certainly  diagnosticated  before 
the  abdomen  is  opened.^  If  abdominal  section  is  done  because 
thrombophlebitis  is  suspected,  many  an  unnecessary  operation 
will  be  performed.  If  the  diagnosis  is  only  made  after  the  ab- 
domen is  opened  for  some  other  indication,  there  will  not  often  be 
an  excuse  for  ligating  or  excising  the  ovarian  veins.  I  have  had 
as  ample  an  opportunity  to  inspect  the  pelvic  and  abdominal  cav- 
ities in  cases  of  puerperal  infection  as  any  of  my  colleagues  in  this 
country,  and  yet  I  have  \'ery  rarely  indeed  seen  a  condition  of  the 
ovarian  veins  that  called  for  their  ligation  or  removal.  Occasion- 
ally in  the  excision  of  necrotic  tumors,  infected  appendages  or 
uterus,  it  is  obviously  advisable  to  place  the  ligature  beyond  a 
thrombus  in  the  vein,  but  thrombophlebitis  as  the  sole  indication 
of  an  operation  and  as  the  only  thing  to  be  removed  is  not  yet 
demonstrated  to  the  satisfaction  of  the  majority  of  surgeons. 

Following  these  general  statements   in  regard  to  abdominal 

'"Berliner  Klin.  Wochenschr. ,"  1908,  p.  6. 

^"Mahler's  sign,"  a  steady  increase  in  pulse-rate  without  corresponding  eleva- 
tion of  temperature  i^Klettc7- puis)  \  pain  in  the  loins;  tympany;  palpation  of  the 
thrombi  may  indicate  thrombosis  of  the  pelvic  veins,  but  none  of  these  signs  is  to  be 
depended  upon  absolutely. 


744  PATHOLOGY  OF  THE   PUERPERIUM. 

section  for  puerperal  sepsis,  it  is  now  more  convenient  to  describe 
in  detail  the  different  kinds  of  operations  required  for  the  various 
forms  of  intra-abdominal  septic  inflammations. 

Abdominal  Section  for  Intraperitoneal  Abscesses  and  Diffuse 
Suppurative  Peritonitis. — The  situation  and  extent  of  localized 
suppuration  within  the  abdominal  cavity  vary  greatly.  A 
quarter  of  the  abdominal  cavity  may  be  filled  with  pus,  the  huge 
abscess-cavity  being  thoroughly  walled  off  by  dense  exudate 
from  the  rest  of  the  abdominal  cavity.  A  smaller  accumulation 
of  pus  about  the  orifice  of  the  tube  is  not  uncommon.  Occasionally 
two  or  three  abscesses  the  size  of  an  orange  are  found  between 
coils  of  intestine  quite  far  removed  from  one  another,  and  with- 
out apparent  connection  with  the  genital  tract.  Abscesses  are 
found  also  between  the  fundus  uteri  and  adjoining  structures^the 
abdominal  wall  near  the  umbilicus,  the  caput  coli,  and  the  sigmoid 
flexure.  In  these  cases  infection  travels  through  a  sharply-defined 
area  of  uterine  wall  and  appears  in  the  same  limits  on  its  peritoneal 
investment.  Exudate  and  adhesions  immediately  w^all  off  the 
infected  area,  with  the  result  of  an  encapsulated  abscess  between 
the  uterine  wall  and  the  structure  nearest  to  it  at  the  time  of  inflam- 
mation. The  treatment  of  these  abscesses  is  evacuation,  cleansing, 
and  drainage.  The  cleansing  may  be  effected  by  flushing  with 
hot  sterilized  water,  if  the  rest  of  the  abdominal  cavity  can  be 
guarded  from  contamination.  It  is  usually  best  to  avoid  irrigation 
and  in  its  place  to  thoroughly  dry  the  cavities  with  gauze.  For 
drainage,  as  a  rule,  sterile  gauze  with  a  glass  or  rubber  tube  is  best. 
In  certain  cases  of  abscesses  near  the  abdominal  walls  a  rubber 
tube  answers  better  than  the  gauze,  and  in  deep-seated  abscesses 
on  the  base  and  the  back  of  the  broad  ligaments  vaginal  drainage 
by  means  of  gauze  or  rubber  tube  is  preferable.  If  the  work  dur- 
ing the  operation  is  well  done,  there  may  be  little  or  no  subsequent 
discharge,  and  douching  of  the  abscess-cavities  during  con^'ales- 
cence  is  uncalled  for.  Occasionally,  however,  if  the  abscess- 
cavity  is  large  and  well  isolated,  daily  douching  with  sterile  hot 
water  is  an  advantage.  In  diffuse  suppurative  peritonitis  the 
remote  chance  of  success  depends  greatly  upon  the  earliest  possible 
operation,  though  there  are  many  virulent  cases  in  which  nothing 
could  check  the  spread  of  the  intfammation  and  the  deadly  effect 
of  septic  intoxication. 

This  is  not  the  place  to  discuss  the  symptoms  of  diffuse  sup- 
purative peritonitis,  but  one  fact  should  be  insisted  upon  from 
the  operator's  point  of  view.  It  is  usually  supposed  that  true 
diffuse  suppurative  peritonitis  appears  early  after  delivery  ;  it 
may,  however,  develop  at  any  time — as  late  as  four  weeks  after 


PUERPERAL   SEPSIS.  745 

confinement.  The  technic  of  the  operation  is  simple:  A  small 
incision  is  made,  and  the  finger  is  rapidly  swept  about  the  pelvis 
and  abdomen  to  determine  the  condition  of  the  organs;  then  the 
irrigating  tube  is  passed  into  the  cavity  at  the  lowest  angle  of  the 
wound,  and  is  swept  about  in  all  directions,  while  the  return-flow 
is  provided  for  by  two  fingers  of  the  left  hand  distending  the  sides 
of  the  wound,  which  by  the  fingers  and  the  irrigating  tube  is  kept 
gaping  as  though  by  a  trivalve  speculum.  The  irrigating  tube  is 
pressed  far  over  first  on  one  flank  and  then  upon  the  other,  and  the 
tip  is  cut  down  upon  where  it  projects  through  the  abdominal  wall. 
Gauze  and  glass-tube  drainage  into  the  pouch  of  Douglas,  a  gauze 
drain  in  the  flanks  is  provided  for,  and  the  wound  is  left  open,  or, 
at  most,  drawn  together  by  a  stitch  or  two.  Puncture  of  the  pos- 
terior vaginal  vault  and  gauze  drainage  into  the  vagina  should  usu- 
ally be  added.  Rapidity  of  operation  and  the  smallest  possible 
quantity  of  anesthetic  are  essential  to  success. 

Salpiiigo-odpJwrcctomy  for  Puerperal  Sepsis. — An  acute  pyo- 
salpinx  in  the  puerperium  is  very  rare.  It  is  uncommon  for 
acute  septic  infection  after  labor  to  travel  by  the  tubes  alone. 
Infection  usually  occurs  in  the  uterine  muscle,  the  veins,  the 
lymphatics,  or  the  connective  tissue  of  the  pelvis.  When  the 
track  of  the  septic  inflammation  is  confined  to  the  mucous  mem- 
brane of  the  genital  tract,  the  pelvic  peritoneum,  in  a  case  serious 
enough  to  demand  operation  during  puerperal  convalescence, 
becomes  infected,  inflamed,  and  suppuration  quickly  follows,  so 
that  the  operation  is  usually  performed  for  an  intra-peritoneal 
pelvic  abscess.  The  tube  may  be  found  somewhat  swollen, 
inflamed,  dark  red  in  color,  containing  a  few  drops  of  pus,  with 
flakes  of  purulent  lymph  on  its  external  surface,  and  its  removal 
is  required ;  but  the  pyosalpinx  is  a  subordinate  feature  in  the 
pelvic  inflammation.  It  is  the  more  subacute  case,  not  usually 
requiring  operation  in  the  conventional  period  of  the  puerperium, 
that  results  later  in  a  typical  uncomplicated  pus-tube. 

Ovarian  abscess  is  much  more  common  than  pyosalpinx. 
The  infection  may  travel  to  the  ovary,  both  by  way  of  the 
tube  and  by  the  connective  tissue  or  lymphatics  of  the  broad 
ligament.  In  the  latter  case  the  whole  ovary  may  be  infiltrated 
with  a  thin  sero-pus  of  a  particularly  virulent  character,  and, 
unfortunately,  in  excising  the  ovary  the  exposure  of  the  infected 
pelvic  connective  tissue  in  the  stump  may  lead  to  infection  of 
the  peritoneal  cavity  and  to  a  diffuse  suppurative  peritonitis. 

The  commonest  indication  for  salpingo-o6[)horectomy  is  fur- 
nished by  a  pus-tube  antedating  conception  or  by  a  j^re-existing 
<:{on()rrlical  infection   of  the  fjccnilal  canal.     The  strain   of  labor 


746  PATHOLOGY  OF   THE   PUERPERIUM. 

excites  a  fresh  outbreak  of  inflammation  or  leads  to  its  spread, 
and  the  persistence  of  septic  symptoms  with  the  physical  signs  of 
pelvic  inflammation  justifies  operative  interference.  Occasionally 
an  operation  must  be  performed  on  a  presumptive  diagnosis  of 
old  pus-tubes,  based  mainly  upon  the  patient's  history  and  the 
existence  of  serious  septic  symptoms,  with  tenderness  on  abdominal 
palpation  over  the  region  of  the  tube  and  ovary.  The  uterus  is 
much  too  high  in  the  abdominal  cavity  for  a  satisfactory  pelvic 
examination  of  the  uterine  appendages. 

There  is  often  nothing  peculiar  in  the  technic  of  these  opera- 
tions. They  differ,  usually,  in  no  respect  from  similar  operations 
upon  non-puerperal  patients.  The  question  of  removing  the 
uterus  along  Avith  the  tubes  arises,  however,  rather  more  fre- 
quently than  in  the  non-puerperal  woman,  on  account  of  the 
infection  of  the  endometrium  or  of  persistent  metrorrhagia. 
But  in  associated  suppurative  salpingitis,  ovaritis,  and  infection 
of  the  connective  tissue  of  the  broad  ligament,  there  is  a  modifi- 
cation of  the  ordinary  technic,  which  is  of  vital  importance. 
The  tubes  and  ovaries  should  be  excised,  the  blood-vessels 
of  the  broad  ligaments  tied  separately ;  the  cut  edges  of  the 
broad  ligament  should  be  allowed  to  gape ;  the  whole  pelvic 
cavity  should  be  filled  with  gauze  and  drained  by  a  curved  glass 
tube  placed  just  posterior  to  the  uterus.  The  dressings,  sterile 
gauze  and  cotton,  cover  the  tube  and  wound  completely.  They  are 
not  disturbed  for  twenty-four  hours,  when  the  tube  is  sucked  out 
by  a  syringe.  This  is  done  daily  for  three  or  four  days,  when  the 
tube  is  removed.  The  gauze  is  then  withdrawn  gradually,  not 
being  entirely  removed  for  eight  to  ten  days.  xA.pparently  most 
desperate  cases  may  be  saved  by  this  technic. 

Hysterectomy  for  Puerperal  Sepsis. — Every  physician  who  has 
seen  many  cases  of  puerperal  infection  during  operations  or  post- 
mortem is  aware  that  there  are  some  in  which  the  mere  removal  of 
infected  tubes  and  ovaries,  vaginal  section  and  drainage,  or  the 
evacuation  of  pelvic  abscesses  through  the  abdomen  can  not  be 
expected  to  save  the  patient.  There  remain  infected  and  infil- 
trated broad  ligaments  infecting  the  peritoneal  cavity,  or  there  are 
foci  of  suppuration  or  infection  in  the  uterine  body  that  spread  to 
the  peritoneum  or  result  in  septic  metastases.  The  only  hope  for 
the  patient  in  such  cases  lies  in  the  entire  removal  of  all  infected 
areas,  leaving  behind  in  the  pelvis  a  healthy,  non-infected  stump. 
To  effect  this  result  the  excision  of  the  uterus,  the  broad  hgaments, 
the  tubes,  and  the  ovaries  is  required.  In  addition  to  these  cases 
there  are  others  in  which,  if  the  tubes  and  ovaries  must  be  excised, 
the  uterus  might  be  removed  with  advantage,  on  account  of  an 


PLATE    17, 


PUERPERAL    SEPSIS. 


747 


infected  endometrium  or  of  persistent  metrorrhagia.  There  may 
also  be  such  wide-spread  suppuration  and  disintegration  of  the 
broad  hgaments,  with  tubal  inflammation,  that  it  is  easier  to  re- 
move all  the  infected  area  and  to  control  hemorrhage,  by  a  hyster- 
ectomy. Figure  555  represents  such  a  case.  A  pyosalpinx  ante- 
dated conception.  Labor  excited  fresh  inflammation.  The  in- 
fection spread  from  the  tube  downward  through  the  connective 
tissue  of  the  broad  ligament,  resulting  in  its  partial  destruction,  in  a 
thick  infiltration  at  its  base,  and  in  an  abscess  between  its  layers, 
closely  hugging  the  whole  of  one  side  of  the  uterine  body.  It 
was  obviously  impossible  to  remove  the  infected  area  without 
removing  the  womb  as  well.  The  operation,  though  undertaken 
under  the  most  discouraging  circumstances,  was  successful. 


Fig-  554-- 


-Perforation  of  the  uterus  in  a  self-induced  abortion.      Streptococcic  infec- 
tion of  tubes  and  ovaries.      Pan-hysterectomy. 


There  can  be  no  doubt  as  to  the  necessity  of  hysterectomy 
in  the  cases  represented  in  figures  554,  556,  557,  and  558.  There 
were  abscesses  in  the  uterine  wall,  directly  under  the  perimetrium, 
about  to  break  into  the  peritoneal  cavity;  one,  indeed,  did  rup- 
ture during  the  operation.  There  was  a  septic  ulceration  at  the 
placental  site  in  one  case  so  nearly  perforating  the  uterine  wall 
that  by  a  light  touch  during  the  operation  tlie  forefinger  passed 
into  the  uterine  cavity.  There  was  also  a  pyosalpinx  in  these 
cases  that,  judging  by  the  hi.story,  antedated  or  was  coincident  with 
impregnation.  The  operations  saved  the  patients.  In  another 
successful  hysterectomy  for  puerperal  sepsis,  the  author  found  the 


748 


PATHOLOGY  OF  THE   PUERPERIUM. 


"H»S^"- 


Fig.  555- — Suppurative  cellulitis  of  broad  ligament;  hysterectomy  (author's  case). 


Fig.  556. — Suppurative  and  ulcerative  metritis,  salpingitis;  hysterectomy 
(author's  case). 


Fig-    557- — Suppurating    metritis:     a,  n,  a.  Abscess    cavities.       Hysterectomy    two 
weeks  after  labor.      Recovery. 


PUERPERAL    SEPSIS. 


749 


womb  completely  ruptured  at  the  fundus  from  tube  to  tube.  The 
diagnosis  ot"  the  injury  had  not  been  made.  The  operation  was 
undertaken  some  weeks  after  labor,  for  what  was  thought  to 
be  an  intraperitoneal  abscess.  Areas  of  suppuration  were  dis- 
covered, but  the  greater  bulk  of  the  inflammatory  mass  was 
exudate  which  had  shut  off  the  general  peritoneal  cavity  from 


Fig.  558. — Submucous  llbronia  removed  by  hysterectomy  in  the  early  puerperium. 

(Author's  case.) 


infection  through  the  gaping  uterine  wound.  In  cases  of  strepto-, 
coccic  infection  the  whole  uterus  may  be  found  so  necrotic  that 
its  consistence  is  that  of  cheese.  No  hgature  holds  in  it  and 
the  uterine  wall  may  be  pinched  through  anywhere  by  the  thumb 
and  forefinger.  One  might  as  well  expect  a  woman  to  live  with 
a  eanerenous  coil  of  intestine  in  her  abdomen  as  with  such  a 
gangrenous  and  necrotic  uterus.  She  can  only  be  saved,  if  at 
all,  by  a  hysterectomy.  It  may  also  be  necessary  to  remove  the 
uterus  in  the  puerperium  to  get  rid  of  an  infected  fibromyoma,  as 
illustrated  in  figure  558.  This  uterus  was  removed  on  the  fourth 
day  of  the  puerperium,  the  patient's  temperature  having  been 
104°  and  the  pulse  140.  Streptococci  were  ibund  in  the  interior 
of  the  tumor  and  there  was  general  systemic  infection,  with 
phlebitis  and  septic  pneumonia,  but  the  woman  recovered. 

Indications  for  the  Operation. — The  indications  for  h)-sterec- 
tomy  during  puerperal  sepsis  arc  furnished  by  the  condition  of  the 
pelvic  organs  when  they  are  exposed  to  sight  and  touch  after  the 
abdomen  is  opened.      The  conditions   descriljied    are    the    ty])es 


750  PATHOLOGY  OF   THE   PUERPERIUM. 

calling  for  hysterectomy.  It  is  not  often  possible  to  determine 
upon  hysterectomy  before  the  abdomen  is  opened,  but  it  should 
be  remembered  that  in  any  abdominal  section  for  puerperal  sepsis 
hysterectomy  may  be  necessary.  The  surgeon,  therefore,  should 
be  provided  with  the  implements  required  for  amputation  of  the 
womb  in  every  abdominal  section  for  puerperal  sepsis,  and  should 
be  prepared  to  remove  it  for  any  one  of  the  indications  described 
above,  but  should  rest  content  with  the  least  radical  measure  that 
promises  his  patient  safety.  The  operation  that  is  quickest  done 
and  shocks  the  patient  least  is  most  successful,  provided,  of  course, 
that  it  is  adequate.  An  excision  of  one  or  both  cornua  or  of  the 
fundus  may  sufiice  instead  of  a  hysterectomy. 

Technic  of  the  Operation. — There  are  three  points  in  which  the 
technic  of  hysterectom_y  for  puerperal  sepsis  may  differ  from  the 
technic  of  the  operation  performed  for  other  conditions:  One 
is  the  necessity  often  of  doing  pan-hysterectomy;  the  other  is  the 
necessity  often  of  tying  the  ligatures  in  a  broad  ligament  much 
thickened  by  inflammatory  exudate  or  by  ligating  the  blood-vessels 
separately  so  as  not  to  include  an  infected  mass  in  the  ligature. 
The  third  is  the  possibility  of  exsecting  a  portion  of  the  uterus, 
usually  the  fundus  or  cornua,  which  are  necrotic,  while  the  rest 
of  the  uterus  may  be  safely  left. 

The  author  prefers  amputation  of  the  uterus,  leaving  as  little 
cervix  as  possible,  unless  an  examination  of  the  cervix  by  a  spec- 
ulum shows  septic  ulceration  or  exudate  upon  it  or  in  its  canal. 
The  reasons  for  this  preference  for  amputation  of  the  womb  over 
pan-hysterectomy  are  that  the  former  can  be  done  more  quickly^ 


^^f^ 


Fig.  559' — Suppurative  ovaritis  (rear  view). 

there  is  not  the  same  anxiety  about  the  cleanliness  of  the  vagina, 
the  suture  material  is  more  certainly  guarded  from  infection  after- 
ward, and  there  is  less  danger  of  cutting  or  ligating  the  ureters. 
The  thickened  broad  ligaments  are  often  a  source  of  serious 
embarrassment    in   placing   and  tying  the  ligatures   around   the 


PUERPERAL    SEPSIS.  751 

uterine  arteries.  There  is  this  difficulty  to  contend  with  in  the 
majority  of  the  operations.  In  some  cases  the  inflammatory  exu- 
date within  and  below  the  ligature  breaks  down  into  pus,  but  an 
incision  in  the  posterior  vaginal  vault  evacuates  the  pus  and  secures 
an  immediate  disappearance  of  somewhat  alarming  symptoms. 
Vaginal  hysterectomy  is  usually  unsuitable  for  cases  of  puerperal 
sepsis  on  account  of  the  danger  of  clamping  or  ligating  large  masses 
of  infiltrated  and  infected  broad  hgament,  on  account  of  the  stiff- 
ened and  adherent  broad  ligaments,  which  make  downward  trac- 
tion on  the  uterus  difficult  or  impossible,  and  because  it  is  imprac- 
ticable in  a  vaginal  operation  to  explore  the  pelvis  and  abdomen 
for  foci  of  infection  at  some  distance  from  the  pelvic  organs. 


,7^-ri'- 


''M 


'"^        -5^-^,^      '■'■'■/' 


Fig.  560. — Streptococcus  and  staphylococcus  infection  of  the  endometrium  :  a, 
Necrotic  layer  of  the  endometrium  ;  .'),  zone  of  inflammatory  reaction ;  c,  gland 
spaces  ;   d,  blood-vessels  ;  £,  remnants  of  glandular  epithelium  (Bumm). 

Exploratory  Abdominal  Section  for  Puerperal  Sepsis. — An 
exploratory  incision  should  be  made  only  in  cases  of  suspected 
extraperitoneal  pelvic  abscess,  to  confirm  one's  suspicion,  to  be 
certain  that  none  of  the  pelvic  organs,  especially  the  tubes,  are 
diseased,  and  to  determine  the  best  situation  for  the  incision  to 
evacuate  the  abscess- cavity  without  contaminating  the  peritoneal 
cavity.  This  rule  of  practice  would  exclude  exploratory  abdominal 
section  in  cases  with  no  physical  signs  of  pelvic  inflammation, 
but  in  which  there  is  evident  septic  infection  of  a  nature  difficult  to 
determine.  There  are  possible  exceptions  to  the  rule,  however, 
as  in  suspected  pyosalpinx  without  physical  signs,  owing  to  the 
high  position  of  the  recently  emptied  womb  and  of  its  appendages. 

Cases  of  true  extra];eritoneal  pelvic  abscess  due  to  ])uerpcral 
infection,    and    without    intra] )eritoneal    inflammation,    are    rare. 


752  PATHOLOGY  OF   THE   PUERPERIUM. 

There  are  some  gynecologists  who  deny  their  existence,  but  the 
writer  has  had  a  number  of  cases  under  his  charge  in  which  the 
diagnosis  was  established  by  abdominal  section. 

In  some  cases  the  suppuration  is  so  evidently  extraperitoneal 
than  an  abdominal  section  may  be  dispensed  with. 

Vaginal  Section  for  Pelvic  SiippJiration  or  for  Infection  of  the 
Pelvic  Connective  Tissjie. — If  there  are  physical  signs  of  an  ab- 
scess in  Douglas'  pouch  and  no  evidence  of  involvement  of  the 
rest  of  tlie  peritoneal  cavity,  or  if  the  woman's  condition  is  too 
bad  to  admit  of  an  abdominal  section,  a  colpotomy  of  the  poste- 
rior vaginal  \'ault  and  an  irrigation  of  the  pelvic  cavity  with  sterile 
water  is  indicated.  After  cleansing  the  vagina  with  tincture  of 
green  soap  and  a  sublimate  douche,  the  mucous  micmbrane  of 
tlie  posterior  vaginal  vault  is  incised  with  a  knife,  and  then  with 
sharp-pointed  scissors  or  one's  fingers  the  opening  into  the  peri- 
toneal cavit}^  is  completed.  Adhesions  are  cautiously  separated 
so  as  to  avoid  opening  the  general  peritoneal  cavit}'  and  the  pel- 
vic organs  are  carefully  palpated  to  detect  isolated  foci  of  sup- 
puration, which  if  found  are  opened.  The  pelvis  is  irrigated 
through  a  two-way  catheter  with  sterile  water  and  then  packed 
quite  firmly  witli  a  strip  of  iodoform  gauze.  The  vagina  is  also 
packed.  The  pelvic  packing  is  removed  after  two  da3's  or  more 
and  is  replaced  by  a  T-shaped  rubber  drainage-tube  through  which 
the  pelvic  cavity  is  irrigated  daily  with  sterile  water  for  ten  to 
fourteen  days.  Incisions  in  the  lateral  fornices  and  gauze  drainage 
are  of  service  in  suppuration  of  the  parametrium  or  in  accumu- 
lations of  infected  serum  in  it. 

The  Morbid  Anatomy  and  Clinical  History,  the  Diagnosis 
and  Treatment  of  the  Different  forms  of  Infection  and  Septic 
Inflammation  of  the  Genital  Region  After  Labor. — The  mani- 
festations of  puerperal  sepsis  differ  witli  the  various  infecting 
bacteria  that  are  lodged  in  the  genital  tract  or  have  invaded  the 
system,  but  especially  with  the  organs  or  structures  that  are 
involved  in  the  septic  inflammation.  The  terms,  therefore, 
"puerperal  infection,"  "puerperal  sepsis,"  or  "puerperal  fever," 
are  generic  in  significance  and  include  a  number  of  distinct  dis- 
eases, widely  different  in  their  symptoms,  their  prognosis,  and 
their  requirements  for  treatment.  The  lesions  of  puerperal  sepsis 
may  be  found  in  the  mucous  membrane  of  the  genitalia  from  the 
vulva  to  the  abdominal  orifices  of  the  tubes,  in  the  mucous  mem- 
brane of  the  bowel,  and  of  the  urinary  tract,  the  myometrium,  the 
pelvic  connective  tissue,  the  peritoneum,  the  lymphatics,  the  veins, 
and  in  the  parenchyma  of  the  ovaries.  Neighboring  organs  and 
tissues  may  be  involved  secondarily,   as   the  bowels,  appendix, 


PUERPERAL    SEPSIS.  753 

ureters,  and  pelvic  nerves,  and  tumors  of  the  pelvis  and  abdomen 
may  be  the  starting-point  of  septic  infection  and  inflammation. 

Endocolpitis,  Endometritis,  and  Salpingitis. — These  inflamma- 
tions are  most  often  of  the  superficial  suppurative  variety,  in  which 
the  prognosis  is  good,  except  in  the  case  of  the  tubes,  whence  the 
inflammation  may  extend  to  the  peritoneum,  causing  diffuse  peri- 
tonitis or  a  circumscribed  abscess  near  the  fimbriated  extremities, 
usually  involving  the  ovary,  or  may  result  in  a  pyosalpinx. 

The  streptococcic  inflammation  of  these  membranes  with  an 
exudate  and  necrosis  of  tissue  is  much  more  dangerous.  It  may 
be  localized  in  the  vagina  in  the  shape  of  ulcers  near  the  ori- 
fice or  extending  up  the  wall  to  the  cervix.  It  may  be  a  diffuse, 
yellowish-green,  foul-smelling  exudate,  occupying  the  whole  inte- 
rior of  the  uterus,  in  which  streptococci,  the  bacillus  pyocyaneus, 
the  bacillus  foetidus,  and  the  staphylococcus  pyogenes  albus  or  aur- 
eus are  found.  Under  the  necrotic  layer  of  the  endometrium  there 
is  a  layer  of  granulation-cell  infiltration  upon  which  the  woman's 
life  depends.  If  it  is  well  developed,  it  resists  the  invasion  of  the 
septic  micro-organisms.  If  not,  there  is  a  likelihood  of  systemic  in- 
fection of  a  grave  character.  In  rare  instances  the  Klebs-Loffler 
bacillus  may  be  discovered  in  the  pseudomembrane,  showing  that 
the  case  is  one  of  true  diphtheria,  and  the  diphtheria  of  the  vagina 
may  be  associated  with  diphtheria  in  the  throat.^  If  the  diph- 
theric inflammation  affects  the  lower  portion  of  the  vagina,  there 
is  edema  of  the  vulva  in  at  least  two-thirds  of  the  cases. 

Diagnosis. — The  diagnosis  of  these  inflammations  is  made  in 
the  case  of  vaginitis  by  inspection,  in  salpingitis  by  a  combined 
examination,  and  in  endometritis  perhaps  by  the  character  of  the 
lochia,^  or  by  inspection  of  the  cervical  canal,  which  may  be  lined 
with  the  same  exudate  that  covers  the  endometrium.  The  diag- 
nosis between  pseudodiphtheric  membranes  and  true  diphtheria 
can  only  be  made  by  a  bacteriological  examination.  It  is  most 
important  that  this  should  be  done,  for  cases  of  true  diphtheria 
should  be  isolated. 

The  treatment  of  these  inflammations  is  frequently  repeated 
irrigations  of  the  whole  genital  tract.  Sterile  water  is  best  for 
this  purpose.  An  antiseptic  simply  diminishes  the  resisting  power 
of  the  body-cells  without  destroying  the  micro-organisms  that  are 

1  J.  W.  Williams,  five  cases,  loc.  ciL,  to  which  should  be  added  one  of  my  own, 
with  diphtheria  of  the  throat  in  the  husband  and  true  diphtheria  of  the  vagina  in  the 
wife,  demonstrated  by  bacteriological  examination. 

2  A  foul  odor  is  not  distinctive  of  anything  except  decomposition.  The  necrosis 
of  the  endometrium  usually  gives  rise  to  this  symptom.  But  the  worst  streptococcic 
infection  may  be  associated  with  odorless  lochia.  There  is  usually,  however,  a  pro- 
fuse serosanguinolent  or  purulent  discharge,  but  the  lochia  may  be  suppressed. 

4^ 


754 


PATHOLOGY   OF    THE   PUERPERIUM. 


the  cause  of  the  mflanimation.     In  cases  of  septic  endometritis 
the  systemic  symptoms  are  grave,  and  a  supporting,  stimulating 

treatment  is  required  in  addition  to 
the  local  treatment.  In  salpingitis  a 
celiotomy  may  be  demanded.  If  the 
inflammation  is  locahzed  and  the  in- 
flamed area  accessible,  it  should  be 
touched  with  a  nitrate  of  silver  solu- 
tion, oj-foj- 

Metritis  and  Cellulitis  of  Subcutan= 
eous  and  Pelvic  Connective  Tissue ;  Septic 
Metritis. — x\s  a  later  stage  of  septic 
endometritis  all  the  structures  of  the 
womb  may  be  involved — connective 
tissue,  muscles,  lymphatics,  and  often 
the  veins,  especially,  however,  the  first. 
In  the  process  of  the  inflammation  por- 
tions of  the  uterine  muscle  may  be 
undermined  by  ulceration  and  may 
slough  off  (dissecting  metritis).^  Liep- 
mann  reports  a  case  associated  with 
diabetes  mellitus,  and  another  with 
perforation  into  the  bowel.^  A  limited 
area  of  uterine  tissue  may  be  involved, 
not  larger  in  circumference,  perhaps, 
than  a  dollar.  The  inflammation  ex- 
tends directly  through  the  uterine  wall, 
still  confined  within  its  original  limits, 
until  the  peritoneal  covering  is  reached. 
Here  the  inflammatory  process  is  also 
strictly  hmited  by  the  rapid  develop- 
ment of  adhesions  which  bind  the  womb  to  those  structures  in 
the  peritoneal  cavity  nearest  the  diseased  area.  The  uterus  may 
be  anchored  to  the  caput  coli,  the  anterior  abdominal  wall,  and 
the  sigmoid  flexure.  In  these  cases  involution  goes  on  imper- 
fectly, of  course,  for  the  womb  can  not  be  normally  reduced 
in  size,  held  as  it  is  at  a  high  level  in  the  abdominal  cavity  by 
adhesions.  There  are,  however,  besides  the  fixation  and  ar- 
rested involution  of  the  womb,  no  other  local  evidences  of  inflam- 
mation, excepting  some  tenderness  on  pressure.  It  is  usually 
impossible  to  locate  the  intraperitoneal  abscess,  by  abdominal 
palpation  or  combined  examination,  on  account  of  its  situation. 

1  In  63  cases  of  dissecting  metritis,  Offergeld  found  a  mortality  of  25  per  cent., 
"Deutsche.  Med.  Wochenschr.,"  No.  19,  1907. 
2"  Arch.  f.  Gyn.,"  Bd.  Ixx,  H.  2. 


Fig.  561. — Dissecting    metritis 
(Liepmann ). 


PUERPERAL    SEPSIS.  755 

The  course  of  these  cases  is  slow,  but  they  are  ultimately 
almost  certain  to  be  fatal,  for  an  abscess  commonly  develops 
on  the  diseased  area  of  uterine  surface  between  the  uterus 
and  the  structures  attached  to  it,  usually  the  bowel  or  omen- 
tum. A  bacteriological  examination  of  some  of  these  cases 
has  shown  the  presence  in  the  uterine  wall  of  pyogenic  staph)-- 
lococci. 

If  the  pelvic  connective  tissue  is  involved,  it  is  at  first  edema- 
tous. The  senuxL  is  then  absorbed,  leaving  a  dense  infiltrate,  if 
there  has  been  much  cell-proliferation,  or  entirely  disappearing 
if  the  cell-element  is  scanty. 

The  infiltrate,  if  not  too  extensive,  is  likewise  absorbed  in 
about  four-fifths  of  all  cases.  Occasionally,  however,  in  about 
one-fifth  of  the  cases  an  abscess  results,  which  may  be  opened 
above  Poupart's  ligament,  or  through  the  vaginal  vault  without 
entering  the  peritoneal  cavity,  but  which  may  spontaneously 
rupture  into  the.  abdominal  cavity,  or  may  perforate  the  rectum, 
bladder,  vagina,  or  uterus. 

Diagnosis. — The  diagnosis  of  metritis  is  difficult.  The  womb 
is  large  in  size,  the  walls  feel  boggy,  and  the  uterus  is  very  sensitive 
to  pressure;  but  it  is  almost  impossible  to  be  positive  that  metritis 
exists  unless  one  can  feel  an  abscess  in  its  walls  by  an  intra-uterine 
examination,  or  unless  the  collection  of  pus  breaks  into  the  uterine 
cavity. 

If  the  abdomen  must  be  opened  for  the  septic  infection,  the 
condition  of  the  womb  is,  of  course,  easily  determined.  Ab- 
scesses may  be  seen  in  its  walls,  and  ulceration  may  so  nearly 
perforate  them  that  when  the  operator's  finger  is  laid  upon  the 
peritoneal  covering  of  the  womb,  it  penetrates  at  once  into  the 
cavity. 

The  diagnosis  of  pelvic  cellulitis  is  usually  easy  to  establish. 
The  exudate  and  infiltration  can  be  felt  on  a  vaginal  examination. 
It  is  often,  however,  impossible  to  decide  whether  the  inflam- 
mation is  limited  strictly  to  the  pelvic  connective  tissue,  or 
whether  the  peK  ic  peritoneum  is  also  involved.  If  the  exudate 
is  situated  onl}'  upon  one  side  of  the  womb  and  does  not  involve 
Douglas'  pouch,  one  has  the  right  to  suspect  pelvic  cellulitis 
without  pelvic  peritonitis,  but  in  my  experience  it  has  almost 
always  been  necessary  to  open  the  abdomen  before  obtaining  a 
positive  answer  to  tliis  question. 

Trcatinoit. — Occasionally,  septic  metritis  ends  in  recovery 
by  the  discharge  of  pus-collections  into  the  uterine  cavity,  or  by 
the  resolution  of  innamniation.  But  the  worst  cases  demand  hys- 
terectomy. Cellulitis  yields  in  the  majority  of  cases  to  rest  in 
bed,  countcrirritation,  the  ice-water  coil  or  poultices  over  the 
lower  abdomen,  and  hot  vaginal  douches.     If  it  fails  to  do  so,  an 


756  PATHOLOGY  OF   THE   PUERPERIUM. 

abdominal  section  should  be  performed,  in  order  to  be  sure  that 
the  peritoneum  is  not  involved.  If  the  inflammation  is  found, 
after  the  abdomen  is  opened,  to  be  confined  strictly  to  the  pelvic 
connective  tissue,  the  abdominal  wound  should  be  closed,  and 
the  infected  area,  if*  it  has  suppurated,  should  be  opened  by 
an  incision  above  Poupart's  ligament,  or  through  the  vaginal 
vault. 

Pelvic  Peritonitis  and  Diffuse  Peritonitis. — Pelvic  peritonitis  is 
the  result  of  the  extension  of  a  septic  endometritis,  either  through 
the  tubes  or  directly  through  the  tissues  of  the  womb,  or  it  fol- 
lows pelvic  cellulitis,  the  germs  penetrating  the  peritoneum  be- 
tween the  endothelial  cells  or  through  the  lymphatic  interspaces. 
In  an  extension  through  the  tubes  or  by  the  spread  of  a  cellulitis 
the  ovaiy  is  likely  to  be  involved,  and  an  ovarian  abscess  develops. 
A  leakage  of  lochial  or  catarrhal  discharge  through  the  abdominal 
orifice  of  the  tubes  is  by  no  means  uncommon.  It  is  followed  by 
a  sharp  localized  peritonitis,  though  it  is  not  certain  that  the 
discharge  is  always  septic.  It  may  be  simply  irritating.  The 
infected  or  irritated  region  may  be  surrounded  by  large  areas 
of  peritoneal  exudate.  A  large  section  of  the  abdominal  cavity, 
one-fourth  or  more,  may  be  thus,  as  it  were,  solidified. 

On  palpation,  the  abdominal  contents  feel  hard  as  stone,  with 
the  muscles  of  the  abdominal  wall  involuntarily  fixed  over  them 
for  protection,  on  account  of  great  sensitiveness  to  pressure. 
Occasionally,  the  exudate  communicates  to  the  fingers  a  sensation 
as  though  snow  were  being  kneaded  through  a  covering  of  some 
flexible  material.  The  symptom^s  are  not  alarming,  and  the 
common  termination  of  this  kind  of  peritonitis  is  recovery.  The 
exudate  is  absorbed,  the  tenderness  disappears,  the  temperature 
sinks  to  normal,  and  no  ill-effects  are  left  behind  ;  but  the  exu- 
date may  break  down  and  encapsulated  abscesses  may  thus  be 
formed,  opening  into  the  bowel,  into  the  bladder,  through  the 
abdominal  walls  at  the  umbilicus,  or  possibly  undergoing  caseous 
changes. 

General  peritonitis  after  labor  may  result  from  an  exten- 
sion of  pelvic  peritonitis  ;  from  infection  through  rents  in  the 
vaginal  or  uterine  walls  ;  from  the  rupture  of  old  pus-collections 
in  the  tubes  or  elsewhere  in  the  pelvis ;  from  putrefaction 
of  tumors  in  the  pelvis,  as  of  dermoids  and  fibroids ;  from 
the  transmission  of  pathogenic  bacteria  by  the  lymphatics,  and 
from  the  extension  of  septic  inflammation  through  the  bladder- 
walls. 

Perforating  gastric  and  duodenal  ulcers,  ruptured  abscesses 
in  the  spleen  or  liver,  are  possible  causes  of  septic  peritonitis  in 
the  puerpera. 


PUERPERAL  SEPSIS. 


7S7 


If  the  suppurative  peritonitis  is  not  limited,  the  intestines 
are  hghtly  glued  together;  are  bathed  in  a  thin  pus,  which 
lies  in  pools  between  their  coils  and  are  covered  with  a  yellow- 
ish exudate,  which  can  be  stripped  off,  leaving  a  raw,  bleeding- 
surface. 

There  is  a  form  of  septic  peritonitis  so  virulent  and  poisonous 
that  no  signs  of  inflammation  accompany  it,  and  the  patient  dies 
before  pus  or  exudate  can  be  formed  {peritonitis  lymphatica). 

The  abdomen  is  found,  after  death,  filled  with  a  dirty  fluid, 
composed  of  serum,  some  blood,  and  numberless  micrococci. 

In  all  forms  of  septic  peritonitis  the  coats  of  the  intestines 
are  paralyzed  and  tympanites  is  marked. 


Day  of 
Disease 

103° 
102° 
101° 
100° 
99° 

M 

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E 

M 

£_ 

M 

e 

M 

E 

M 

^ 

M 

i. 

Fy 

'; 

-k 

t 

^ 

/ 

h\ 

y 

-N 

h 

-i 

\ 

■ 

"^ 

y 

•    , 

' 

.^ 

^^ 

_• 

•-, 

^•^ 

i^i 

^^ 

^^ 

_!. 

Fig.  562. — Temperature-chart  of  diffuse  purulent  peritonitis. 


Diagnosis. — The  diagnosis  of  pelvic  peritonitis  is  made  by  the 
general  symptoms  and  by  the  local  physical  signs.  There  is 
fever  of  varying  degree,  with  accelerated  pulse  and  general 
depression.  There  is  marked  tenderness  over  the  lower  ab- 
domen, and  there  is  tympanitic  distention  of  the  abdomen.  Aus- 
cultation shows  absent  or  feeble  peristalsis.  On  making  a  vaginal 
examination  exudate  is  found  in  Douglas'  pouch  and  to  the  sides 
of  the  womb,  which  is  firmly  fixed.  The  exudate  is  usually  ex- 
quisitely sensitive  to  pressure.  It  is  sometimes  firm  and  hard, 
and,  again,  may  be  soft  and  boggy.  If  the  latter  condition  persists, 
it  is  indicative  of  suppuration. 

General  peritonitis  is  usually  sudden  in  its  onset  and  very 
rapid  in  its  course.  It  occurs  ordinarily  in  the  first  few  days  of 
the  puerperium. 

There  is  extreme  distention  of  the  abdomen  ;  a  rapid,  running, 
wiry  pulse  ;  an  extremely  anxious,  pinched  expression  of  the  fiice  ; 
the  eyeballs  are  sunk  deep  in  their  sockets  and  there  are  dark  rings 
under  them;  there  is  a  peculiar  grayish   color  of  the  skin,  and, 


758 


PATHOLOGY  OF  THE  PUERPERIUM. 


perhaps,  high  fever,  agonizing  pain,  and  possibly  dulhiess  on 
percussion  at  certain  points  in  the  abdominal  cavity;  but  the  latter 
signs  may  be  entirely  absent.  There  may  be  absolutely  no  tender- 
ness nor  pain,  no  dullness,  and  very  little  fever.  Malignant  cases 
may  end  fatally  within  forty- eight  hours 
from  the  first  appearance  of  symptoms, 
with  a  temperature  never  exceeding  iob|° 
by  the  mouth,  though  the  rectal  temperature 
is  often  much  higher. 

Treatment. — It  is  difficult  to  determine 
at  first  whether  a  pelvic  peritonitis  will  end 
in  suppuration  or  resolution.  As  the  latter 
is  always  possible,  the  treatment  should  at 
first  be  expectant.  Counterirritation  and 
poultices  may  be  used  over  the  lower  ab- 
domen ;  an  ice-bag  or  the  ice-water  coil  is 
often  of  the  greatest  service  ;  the  bowels 
may  be  thoroughly  drained  by  a  strong 
purgative,  so  as  to  diminish  intra-abdominal 
congestion  and  inflammation,  and  copious 
hot  vaginal  douches  may  be  given.  If  the 
symptoms  persist  much  beyond  forty-eight 
hours  in  their  original  intensity  under  this 
form  of  treatment,  suppuration  has  prob- 
ably occurred,  or  must  be  expected.  In 
such  a  case  the  abdomen  should  be  opened. 
Abscesses,  if  they  are  found,  must  be 
evacuated  and  the  cavities  thoroughly 
cleaned,  disinfected,  and  drained.  Dis- 
tended tubes  and  ovaries  must  be  removed, 
and  it  may  be  necessary  to  perform  hyster- 
ectomy. If  the  abscess  is  localized  in 
Douglas'  pouch,  or  if  the  patient's  condition  is  very  bad,  vaginal 
section  is  preferable,  followed  by  drainage  through  the  posterior 
cul-de-sac. 

General,  diffuse,  suppurative  peritonitis  is  almost  invariably 
fatal,  let  the  treatment  be  what  it  may.  The  only  possible  chance 
for  such  a  case  is  in  the  earliest  possible  performance  of  an 
abdominal  section  with  free  irrigation  of  the  abdominal  cavity  and 
drainage  through  the  abdominal  wall,  the  flanks,  and  the  posterior 
vaginal  vault;  but  even  though  this  be  done  within  twelve  hours 
of  the  onset  of  symptoms,  it  Avill  almost  invariably  be  of  no  avail. 
Once  in  a  long  while,  however,  a  case  of  tme  diffuse  suppurative 
peritonitis  may  be  saved  by  a  timely  operation. 

Fowler  advocates  raising  the  head  of  the  bed  after  these  opera- 


Fig-  563- — Clots  in 
sinuses  of  uterine  walls 
(from  specimen  in  the 
Army  Medical  Museum, 
Washington,  D.  C). 


PUERPERAL   SEPSIS.  759 

tions,  so  that  the  patient's  body  has  a  downward  slant  of  30  degrees 
or  more,  to  facilitate  drainage/  Combined  with  Murphy's  con- 
tinuous instillation  of  salt  solution  in  the  rectum,  it  should  be 
adopted  in  the  after-treatment  of  operations  for  peritonitis,  but  noth- 
ing like  the  results  ]Murphy  reports  can  be  expected  in  the  strep- 
tococcic peritonitis,  which  is  the  form  commonly  seen  after  child- 
birth. 

Uterine  and  Para=uterine  Phlebitis. — ^The  veins  of  the  uterus 
and  of  the  surrounding  connective  tissue  are  prone  to  thrombosis 
by  reason  of  the  sluggish  circulation,  the  pressure  during  preg- 
nancy, and  the  altered  constitution  of  the  blood  in  a  puerpera. 
The  clots,  when  formed,  may  be  directly  infected,  usually  at  the 
placental  site.  They  may  then  be  disintegrated  and  swept  into 
the  circulation,  producing  pyemia,  or  the  veins  may  be  infected 
from  passing  through  a  septic  region.  Then  the  walls  are  first 
involved,  the  blood  clots,  and  perhaps  thus  opposes  the  further 
spread  of  the  process.  Or,  more  likely,  the  clot  is  in  its  turn 
infected,  disintegrated,  and  carried  into  the  larger  venous  trunks. 
In  the  course  of  the  inflammation  clots  may  be  dislodged  or 
vessel-walls  may  be  perforated  and  a  most  serious  hemorrhage 
may  result.  Repeated  bleedings  may  occur  at  short  or  long 
intervals.  This  form  of  septic  infection  is  least  likely  to  produce 
peritonitis  or  local  inflammation  in  the  pelvis,  but  is  most  likely 
to  produce  pyemia. 

If  infected  emboli  are  swept  into  the  circulation,  they  may 
find  lodgment  in  many  different  parts  of  the  body,  causing 
abscesses  in  the  abdominal  viscera,  the  eyeballs,  the  brain  or 
spinal  cord,  the  lungs,  the  pleura,  or  in  the  subcutaneous  con- 
nective tissue  at  any  portion  of  the  body-surface.  I  have  seen, 
for  example,  the  whole  anterior  portion  of  the  left  leg  and  the 
right  forearm  riddled  with  the  abscesses  of  suppurative  cellulitis 
in  the  course  of  a  case  of  puerperal  phlebitis. 

The  thrombosis  in  a  puerpera  is  not  always  limited  to  the 
veins  of  the  uterus  and  of  the  pelvis.  I  have  observed,  for 
example,  a  fatal  case,  death  occurring  on  the  seventeenth  day 
postpartum,  preceded  by  convulsions  and  coma.  It  was  not 
known  whether  the  woman  had  had  fever  after  delivery.  In  the 
postmortem  examination  the  longitudinal  and  lateral  sinuses  of 
the  brain  were  found  perfectly  solid  witli  thromboses.  There 
had  been  a  very  severe  postpartum  hemorrhage,  and  there  were 
evidences  in  and  about  the  womb  of  septic  phlebitis.  Maygrier 
and  LetuUe  report  a  case  of  puerperal  thrombosis  of  the  mes- 
enteric vein  with  partial  necrosis  of  the  small  intestine.- 

'  "  Med.  News,"  May  28,  1904. 

^  "Bull.  Soc.  Anat.  de  Paris,"  tome  Ixxiii,  p.  507. 


760 


PATHOLOGY  OF   THE   PUERPERIUM. 


An  almost  constant  accompaniment  of  uterine  and  pelvic 
phlebitis  is  phlegmasia  alba  dolens. 

Diagnosis.— T\\^  characteristic  signs  of  uterine  and  pelvic  phle- 
bitis are:  a  high,  irregular,  and  long-continued  fever;  profound 


Fig.  564. — Case  of  phlebitis  in  which  there  was  a  sharp  rise  of  temperature  after 
two  attempts  to  disinfect  the  birth-canal. 


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Fig.  565. — A  case  of  phlebitis.  Twice  the  temperature  rose  above  107°,  as  a 
result  apparently  of  an  intra-uterine  douche,  the  hyperpyrexia  occurring  directly  after 
it.      Recovery. 

depression  and  great  rapidity  of  pulse,  with  an  entire  absence  of 
all  local  symptoms  of  septic  infection  or  of  septic  inflammation. 
The  womb  is  normal  in  size,  is  freely  movable,  and  involution 
goes  on  uninterruptedly.  There  is  no  tenderness,  no  tympany. 
Any  interference  with  the  uterus,  as  in  an  attempt  to  disinfect 
its  cavity,  occasions  an  exacerbation  of  the  fever  and  may  cause 
a  serious  hemorrhage.  The  woman's  face  is  apt  to  show  a 
dusky  flush  on  one  or  both  cheeks,  and  red  splotches  appear  on 
other  parts  of  the  body,  especially  upon  the  chest. 


PUERPERAL    SEPSIS.  76 1 

In  the  course  of  the  disease  evidences  of  pyemia  may  appear, 
and  phlegmasia  alba  dolens  will  almost  surely  develop,  either  as 
the  predominant  symptom  or  as  a  mere  incident  in  the  course  of 
the  disease.  It  is  a  common  experience  to  note  intermissions  of 
apparently  perfect  health  with  a  normal  temperature  lasting  per- 
haps for  several  days  and  then  a  recurrence  of  all  the  symptoms 
in  their  original  intensity. 

Treatment. — The  treatment  of  phlebitis  should  consist  of  a 
preliminary  disinfection  of  the  uterine  cavity.  In  a  perfectly 
typical  case  this  will  prove  unnecessary  or  even  harmful,  but  it 
is  so  difficult  to  determine  whether  or  not  there  remains  in  the 
womb  infected  and  necrotic  endometrium,  that  the  risk  of  doing 
the  patient  some  damage  should  be  incurred  in  order  to  escape 
the  serious  error  of  leaving  in  the  uterus  material  which,  if  not 
removed,  may  result  in  her  death. 

The  successful  treatment  of  the  phlebitis  itself  consists  of 
absolute  rest  and  stimulation.  Enormous  quantities  of  alcohol 
may  be  used  with  advantage,  and  as  much  food  of  an  easily- 
digested  character  should  be  administered  as  the  patient  can 
assimilate.  The  vast  majority  of  these  cases  end  in  recovery, 
but  the  disease  may  run  a  course  of  weeks  or  months.  On 
account  of  the  danger  of  a  recurrence  of  the  symptoms  the 
patient  should  be  kept  in  bed  for  at  least  ten  days  after  the 
temperature  has  become  normal.  It  has  been  proposed  to  ligate 
and  excise  the  ovarian  and  even  the  hypogastric  vein  in  case  of 
septic  thrombosis  in  the  former.^  This  treatment  does  not  appeal 
to  the  author  as  reasonable  (see  p.  743). 

Phlegmasia  Alba  Dolens,  or  Milk=leg. — This  condition  receives 
its  name  from  the  appearance  that  the  leg  presents,  and  from 
the  old  idea  that  most  of  the  inflammatory  conditions  of  the 
puerperium  were  due  to  a  metastasis  of  milk.  There  are  two 
distinct  kinds  of  phlegmasia  after  delivery.  In  one  there  is  an 
occlusion  of  the  veins  of  the  pelvis  and  of  the  lower  extremities, 
interfering  with  the  circulation  and  leading  to  an  intense  edema. 
The  leg  is  enormously  swollen  ;  the  skin  is  tense,  glistening,  and 
milk-white  in  color.  The  swelling  is  so  great  that  the  skin  does 
not  at  first  pit  on  pressure.  In  the  other  class  of  cases  there  is 
a  septic  inflammation  of  the  connective  tissue  of  the  pelvis  and  of 
the  thigh,  the  infection  spreading  from  the  perineum  or  from  the 
deeper  pelvic  fascia  through  some  of  the  larger  foramina  of  the 
pelvis.  Cases  of  the  first  class — thrombotic  phlegmasia — are  much 
more  common  than  those  of  the  .second — cellulitic  phlegmasia. 

Thrombotic  phlegmasia  should  be  also  divided  into  two 
classes.   In  one  the  thrombosis  is  primary,  and  is  due  to  the  pres- 

'  International  Gynecological  Congress,  Rome,  1902. 


762  PATHOLOGY  OF   THE    PUERPERIUM. 

sure  to  which  the  blood-vessels  are  subjected  during  pregnancy, 
to  extensions  of  thrombi  from  the  uterine  sinuses,  to  stagnation  of 
the  blood-current.  In  the  other  there  is  a  septic  inflammation 
of  the  blood-vessel  wall,  leading  to  secondar}'  thrombosis.  The 
clinical  manifestations  are  quite  distinct  in  the  two  kinds  of 
cases  ;  in  the  first  there  is  little  fever  and  few  systemic  symp- 
toms ;  in  the  second  the  fever  is  high  and  the  systemic  symp- 
toms grave,  but  one  often  sees  the  first  pass  into  the  second  by 
an  infection  of  the  blood-clot. 

Symptoms. — Usually  from  the  tenth  to  the  thirtieth  day^  there 
develop  a  heaviness  and  stiffness  in  the  leg,  with  pain,  especially 
in  the  calf  of  the  leg,  soon  followed  by  swelHng,  beginning  at 
the  ankle  and  gradually  ascending  to  the  groin,  if  the  phlegmasia 
is  due  to  thrombosis  of  the  veins ;  or  at  Poupart's  ligament  or 
the  buttocks,  extending  down  the  thigh,  if  the  condition  is  due  to 
a  septic  inflammation  of  the  connective  tissue.  In  the  former 
case  there  is  very  likely  to  be  tenderness  along  the  course  of 
the  femoral  vein,  w^hich  may  also  be  marked  by  a  line  of  inflam- 
matory redness.  Other  superficial  veins  may  be  likewise  affected, 
and  may  appear  as  red  streaks  under  the  skin.  The  lymphatics 
may  also  be  involved,  becoming  thickened  and  reddened.  There 
is  ahnost  always  sUght  fever,  which  usually  precedes  the  swell- 
ing of  the  leg  and  disappears  commonly  long  before  the  swelhng 
subsides.  There  is  also  gastric  and  intestinal  disturbance,  with 
a  foul  tongue,  loss  of  appetite,  nausea,  and  vomiting.  There  is 
profound  physical  depression,  sometimes  with  great  restlessness 
and  sleeplessness.  There  is  often  a  dusky  flush  upon  one  or  both 
cheeks. 

Phlegmasia  is  a  very  frequent  complication  of  septic  phlebitis, 
in  which  disease  it  may  occur  as  a  mere  incident,  the  swelling  of 
the  leg  appearing,  perhaps,  during  the  height  of  the  septic  fever, 
lasting  a  comparatively  short  time,  and  disappearing  entirely 
long  before  the  subsidence  of  the  other  symptoms  of  the  septic 
infection. 

The  left  leg  is  more  frequently  affected  than  the  right. 
Occasionally,  one  leg  is  involved  after-  the  other,  and  possibly 
they  may  both  be  swollen  at  the  same  time. 

Frequency. — Phlegmasia  is  a  comparatively  rare  disease. 

As  already  stated,  the  thrombotic  variety  of  phlegmasia  is 
very  much  more  common  than  the  cellulitic  kind.  Of  twenty-five 
cases  or  more  under  my  observation,  only  one  was  of  the  latter  sort. 
Causes. — The  commonest  cause  of  phlegmasia  is  a  septic  in- 
flammation of  the  blood-vessel  walls,  beginning  at  the  placental 

1  Phlegmasia  may  antedate  labor,  and  I  liave  seen  it  appear  seven  weeks  after 
delivery. 


PUERPERAL    SEPSIS.  763 

site  and  extending  through  the  pampiniform  or  utero-vaginal 
plexuses  down  to  the  femoral  vein,  or  upward  through  the  sper- 
matic vessels  to  the  vena  cava. 

In  consequence  of  the  inflammation  of  the  vein-walls  the 
blood  clots  in  the  vessel,  and  the  clot  extends  even  more  rapidly 
than  the  inflammation  of  the  vessel-walls.  Occasionally,  the 
thrombus  is  the  primary  occurrence.  This  is  proven  by  the 
cases  which  develop  before  labor.  In  these  instances  the 
pressure  of  the  pregnant  womb  upon  the  pelvic  vessels,  the 
stagnation  of  the  blood-current,  and  the  composition  of  the 
blood  all  conduce  to  the  formation  of  extensive  clots.  But 
even  if  the  primary  occurrence  is  a  thrombosis,  the  clot  usually 
becomes  infected  in  time  ;  so  that  almost  every  case  of  phleg- 
masia, some  time  in  its  course,  is  septic  in  its  nature.  It  has 
been  claimed  by  Widal  that  the  thrombus  of  the  femoral  vein 
after  child-birth  is  explained  by  the  presence  of  pathogenic 
micro-organisms  in  the  blood,  which  fasten  themselves  upon  the 
vein-wall  near  Poupart's  ligament,  where  the  circulation  is  sluggish 
and  stagnant,  especially  when  the  woman  first  stands  up,  and  is 
favorable,  on  this  account,  to  the  deposition  of  bacteria  along  the 
walls  of  the  blood-vessel.  This  theoiy  very  likely  has  some  truth 
in  it.  It  would  explain  the  occurrence  of  phlegmasia  in  the 
course  of  infectious  diseases,  such  as  typhoid  fever  and  grip  ;  and 
it  would  also  explain  the  thrombosis  of  other  vessels  than  those 
in  the  pelvis,  as,  for  instance,  of  the  sinuses  in  the  brain. 

Prognosis. — The  outlook  in  a  case  of  phlegmasia  is  always 
somewhat  doubtful  ;  the  dangers  are  manifold.  There  may  be 
pyemia  from  the  detachment  of  a  portion  of  an  infected  clot ; 
abscesses  may  develop  in  the  vessel  itself,  extending  rapidly  to 
surrounding  structures  until  the  thigh-muscles  are  dissected  one 
from  the  other  by  an  ulcerative  process  and  the  wdiole  limb 
becomes  infiltrated  with  a  foul  sero-pus.  The  circulation  may  be 
so  interfered  with  that  gangrene  of  the  limb  occurs,^  or  the 
vena  cava  may  be  blocked  up,  practically  cutting  off  the  whole 
lower  portion  of  the  body  from  its  blood-supply  by  preventing 
the  return  flow.  Or,  if  there  is  only  partial  compensation  for 
the  obstructed  circulation,  there  is  a  chronic  congestion  of  the 
limb,  which  is  permanently  enlarged  and  stiffened,  and  will 
swell  beyond  its  usual  proportions  if  the  woman  is  much  upon 
her  feet.      The  passiv^e   congestion,  if  long   continued  and  exag- 

1  Wormser  has  collected  66  cases  of  puerperal  gangrene,  58  in  the  lower  extremi- 
ties, 8  in  the  upper  extremities,  skin  of  the  face  and  of  the  buttocks.  The  cause  may 
be  found  in  the  arteries  or  in  the  veins.  In  the  former  there  may  be  embolism,  end- 
arteritis, and  thrombosis.  In  40  of  the  cases  the  arteries  were  alone  obstructed  in 
18;  the  veins  alone  in  13  ;  the  arteries  and  veins  in  13.  ("Wiener  klin.  Rundschau," 
No.  5,  1904.) 


764  PATHOLOGY  OF   THE   PUERPERIUM. 

gerated    in    degree,   may    even   result   in    the    development    of 
elephantiasis. 

Most  to  be  feared  of  all  is  the  detachment  of  a  large  portion 
of  the  thrombus  and  a  consequent  pulmonary  embolism,  with 
sudden  death. 

The  most  favorable  course  in  these  cases  is  absorption  of  the 
thrombus  and  the  restoration  of  the  circulation  through  the 
obstructed  blood-vessel.  The  next  most  favorable  termination 
is  a  firm  organization  of  the  thrombus,  the  obliteration  of  the 
vein,  and  a  satisfactory  compensatory  circulation  by  means  of 
the  gluteal  vessels  or  through  the  epigastric  veins. 

Treatment. — The  most  important  features  of  the  treatment 
may  be  outlined  as  follows:  Absolute  quiet  and  rest  flat  uporL 
the  back  in  bed,  in  order  to  avoid  embohsm;  elevate  the  limb, 
in  order  to  facilitate  the  return  circulation  as  much  as  possible; 
wrap  it  in  cotton,  so  as  to  alleviate  the  feeling  of  cold  and  numbness 
in  it;  and  support  the  system  by  sufficient  food  and  carefully 
regulated  stimulus,  as  the  disease  is  almost  always  asthenic  in 
tendency. 

When  all  symptoms  have  subsided,  when  the  swelling  has 
disappeared,  and  there  is  no  longer  the  slightest  tenderness  along 
the  course  of  the  affected  vein,  the  limb  may  be  restored  more 
quickly  to  usefulness  by  gentle  friction  and  massage.  The  patient 
should  not  be  allowed  to  leave  her  bed  until  about  ten  days  after 
the  complete  subsidence  of  fever  and  local  tenderness,  for  fear  of 
embolism,  which  is  always  possible  until  the  clot  has  become  ab- 
sorbed or  is  firmly  organized. 

In  the  cellulitic  variety  of  phlegmasia  the  fever  is  much 
higher,  the  disease  is  more  acute,  and  the  inflammation  more 
intense.  There  is  almost  a  certainty  of  suppuration  in  the  con- 
nective tissue  of  the  thigh.  The  first  formation  of  pus  should 
be  carefully  watched  for,  so  that  the  abscesses  may  be  opened 
in  time  to  avoid  extensive  burrowing.  Extensive  and  multiple 
incisions  may  be  required  to  evacuate  the  pus  and  to  drain  the 
diseased  areas,  even  early  in  the  course  of  the  inflammation. 

Abscesses  may  also  develop  in  the  phlebitic  and  thrombotic 
variety  of  phlegmasia,  along  the  course  of  the  femoral  vein,  in 
the  popliteal  space,  or  in  the  calf  of  the  leg. 

Septicemia,  Sapremia,  or  Putrid  Absorption. — By  these  terms  is 
meant  the  absorption  into  the  system  of  ptomains  or  toxins 
generated  by  the  putrefaction  of  hypertrophied  decidua,  shreds 
of  membranes,  blood-clots,  pieces  of  placenta,  or  of  the  lochia! 
discharge. 

This  is  quite  a  common  form  of  septic  fever  after  child-birth. 


PUERPERAL  SEPSIS. 


765 


It  is  a  frequent  accompaniment  of  microbic  invasion  of  the  system. 
IMot  only  anaerobic  saprophytes  but  pathogenic  bacteria  of  all 
kinds  are  productive  of  toxins.  Occasionally,  they  are  excluded 
from  the  uterine  cavity  entirely,  in  spite  of  the  presence  of  large 
masses  of  putrescible  material,  as  is  proved  by  a  fetal  head  remain- 
ing in  the  uterus  three  months,  a  placenta  seven  months,  without 
disadvantage  to  the  patient.  Sapremia  may  appear  late  in  the 
puerperium. 

Of  all  forms  of  sepsis  after  child-birth,  sapremia,  if  not  asso- 
ciated with  microbic  invasion  of  the  tissues  beneath  the  endo- 


Fig.  566. — Hypertrophied  and  angiomatous  mass  of  infected  decidua  at  the  placental 
site  ;   hysterectomy  (author's  case). 

metrium,  is  the  least  dangerous  and  the  easiest  cured.  It  may, 
however,  at  any  time  develop  into  one  of  the  forms  previously 
noted,  and  should  never  be  neglected.  It  is  not  at  all  unlikely 
that  streptococci  and  possibly  other  pathogenic  micro-organisms 
in  the  uterine  cavity  may  act  as  saprophytes.  They  are  certainly 
often  associated  with  the  anaerobic  micro-organisms  of  decom- 
position. If  they  are  left  there  too  long,  they  might  invade  the 
system. 

Syniptovis. — Usually  in  the  first  three  days  after  labor  the  tem- 
perature rises  and  the  pulse  is  accelerated.  The  womb  is  foimd 
larger  than  it  should  be,  and  the  lochial  discharge  has  a  foul 
odor.  Often,  however,  sapremia  may  develop  very  late  in  the 
puerperium.  Tliere  may  be  no  foul  odor  whatever  to  the 
disciiargcs,  and  the  involution  ma\'  appear  to  proceed  naturally. 

An  accurate  diagnosis  of  sapremia  is  never  possible,  but  if  a 


766  PATHOLOGY  OF   THE   PUERPERIUM. 

single  disinfection  and  evacuation  of  the  uterine  cavity  is  follovred 
by  an  immediate  disappearance  of  symptoms,  if  blood  cultures 
are  sterile  and  there  are  no  signs  of  local  inflammation  in  the 
pelvis  or  abdomen,  it  is  likely  that  the  patient  is  suffering  from 
septic  intoxication  and  not  septic  invasion.  An  absence  of 
pathogenic  bacteria  in  the  uterine  contents  is  confirmatory,  but 
even  streptococci  may  act  as  saprophytes  on  the  endometrium. 

Treatment. — The  treatment  of  this  form  of  infection  has  been 
described  in  the  general  treatment  of  all  forms  of  sepsis.  It  is  a 
thorousrh  disinfection  and  instrumental  evacuation  of  the  uterus. 
If  the  case  is  one  of  true  sapremia,  the  success  of  this  treatment  is 
almost  immediate. 

Septic  cystitis,  ureteritis  and  pyelitis  may  be  of  the  superfi- 
cial, suppurative  variety  (staphylococcic),  or  ma\'  be  diphtheric 
(streptococcic)  with  the  formation  of  pseudomembrane. 

In  the  latter  case  the  exudate  or  membrane  may  extend  from 
the  bladder  by  the  ureter  to  the  pelvis  of  the  kidney.  There 
may  be  sloughing  of  the  infected  mucous  membrane,  putrefac- 
tion of  the  masses  of  membrane  exfoliated,  and  extension  of 
the  inflammation  through  the  bladder-walls  to  the  peritoneum. 
The  kidney  may  bear  the  brunt  of  the  attack  ;  it  may  be  riddled 
with  abscesses,  or  converted  into  a  large  bag  of  pus.  From 
contiguity  with  the  liver  on  the  right  side,  hepatic  abscesses  may 
also  be  found. 

Causes. — The  most  frequent  cause  is  an  imperfect  aseptic 
technic  in  catheterization.  It  is  possible,  however,  for  micro- 
organisms to  wander  in  by  the  urethra.  The  kidneys  may  possibly 
be  infected  from  the  blood  and  the  bladder  may  be  infected  from 
foci  in  the  pelvis.  Anything  which  lowers  the  vitality  of  the 
urinary  tract  predisposes  to  infection;  namely,  pressure  on  the 
bladder  by  the  fetal  head;  injuries;  overdistention  of  the  blad- 
der; cystocele;  dislocations  of  the  kidney;  renal  calculus;  and  com- 
pression of  the  ureters.  An  infection  of  the  urinary  tract  may 
have  antedated  labor. 

Diagnosis. — The  cystitis  usually  develops  a  {e\\  days  after 
labor,  with  the  ordinary  signs  of  that  affection — frequent  and 
painful  micturition,  slight  elevation  of  temperature,  pus  and 
mucus  in  the  urine,  and  tenderness  on  pressure  over  the  bladder. 
The  symptoms  may  subside  after  a  few  days  and  the  patient  may 
appear  to  be  in  perfect  health,  while  the  inflammation  is  passing 
up  the  ureters,  but  fever  returns  \\ith  added  intensity,  and  all  the 
symptoms  of  septic  infection  may  appear  to  a  most  alarming 
degree.  The  urine  contains  large  quantities  of  pus  and  mucus, 
and  swarms  with  micro-organisms.  There  is  very  likely  tender- 
ness on  pressure  over  one  or  both  kidneys,  and  there  may  be 
intense  pain  in  the  lumbar  region. 


PUERPERAL    SEPSIS. 


767 


Ax.  this  stage  of  the  disease  a  stimulating  treatment  may 
enable  the  patient  to  survive  the  immediate  attack,  though  she 
may  be  left  with  a  chronic  pyehtis.  She  is,  however,  likely  to 
die  of  septic  infection  of  the  kidneys. 

Treatment. — Infection  of  the  bladder  should  never  be  allowed  to 
extend  to  the  ureters  and  kidneys.     On  the  first  symptoms  of  vesical 


Fig.  567. — Necrosis  of  an  inlraligameniai)    huromyoma  removed  in  the  puerperium. 


irritation  and  inflammation  after  labor,  the  bladder  should  be 
washed  out  and  disinfected  through  a  two-way  catheter  with  at 
least  a  quart  of  a  boric  acid  solution  (15  grs.-fSj).  After  the 
irrigation  4  to  6  ounces  of  a  2  to  5  per  cent,  protargol  orargyrol 
solution  may  be  injected  into  the  bladder  and  left  there  until  the 
next  urination.  This  treatment  usually  stamps  out  the  septic 
infection  of  the  vesical  mucosa  in  a  iew  days,  and  there  is  no 
extension  of  the  inflammation.  If  pyelitis  develops,  the  urinary 
disinfectants,  urotropin,  boracic  acid,  salol,  should  be  administered 
with  large  drafts  of  water.  Stimulation  and  support  are  required. 
It  may  be  necessary  to  open  and  drain  the  pelvis  of  the  kidney  on 
one  or  both  sides  by  a  lumbar  incision.  Rarely  nephrectomy  is 
indicated  if  the  disease  is  unilateral.  A  perirenal  abscess  may 
require  evacuation  in  the  course  of  the  inflammation. 

The  differential  diagnosis  of  cystitis  and  pyelitis  is  made  by 
cystoscopy,  catheterizing  the  ureters,  and  a  bacteriological  examina- 
tion of  the  urine.     The  i)yclitis  of  gonorrheal  or  colon  bacillus 


768  PATHOLOGY  OF   THE   PUERPERIUM. 

origin  antedating  labor  is  to  be  differentiated  from  the  puerperal 
infection,  usually  streptococcic.  The  latter  is  much  more  danger- 
ous. 

Septic  proctitis  may  be  the  consequence  of  employing  a 
badly  infected  syringe -nozle  in  the  administration  of  an  enema. 
It  is  only  likely  to  occur  in  hospitals,  and  is  extremely  rare  under 
any  circumstances.  I  have  seen  one  fatal  case.  The  inflammation 
may  be  of  a  superficial  suppurative  or  catarrhal  (staphylococcic) 
or  of  a  diphtheric  character  (streptococcic).  The  latter  is  almost 
certain  to  be  fatal.      The  former  may  end  in  recoveiy. 

Degeneration  and  Putrefaction  of  Pelvic  and  Abdominal  Tumors. 
— The  cystic  tumors  of  the  pelvis  and  abdomen,  usually 
ovarian  cysts,  show  a  disposition  to  twist  upon  their  pedicles  in 
the  puerperium,  and  they  may  thus  become  gangrenous.  Der- 
moid cysts  are  particularly  likely  to  undergo  degeneration. 
Solid  tumors  (fibroids),  from  the  squeezing  and  bruising  to 
which  they  are  subjected  in  labor,  and  from  their  low  vitality, 
are  likely  to  become  necrotic.  The  diagnosis  of  these  cases 
is  not  difficult.  The  presence  of  the  tumor  should  be  recognized, 
and  inflammation  or  degeneration  in  it  must  be  suspected  if  the 
patient  develops  fever  and  the  signs  of  sepsis  after  delivery. 

The  treatment  is  the  timely  removal  of  the  infected  growth. 
If  there  is  any  elevation  of  temperature  at  all  after  deliveiy,  the 
tumor  should  be  removed  at  once,  without  waiting  for  indubitable 
evidence  of  degenerative  changes  in  it. 

Tetanus. — This  rare  disease  of  the  puerperium  is  due  to  an 
infection  of  the  genital  canal  by  the  tetanus  bacillus.  The  micro- 
organism may  be  conveyed  by  a  dust-laden  atmosphere,  by 
actual  contact  with  hands  or  implements  that  are  infected  with 
the  germ,  or  by  muddy  water  containing  a  heavy  sediment  of  soil. 
The  proximity  of  the  lying-in  room  to  a  stable  was  held  account- 
able for  the  disease  in  one  case.-  In  Vinay's  io6  cases  the  placenta 
was  manually  separated  in  20,  a  tampon  was  inserted  in  17. 

Heyse  ^  claims  that  a  tetanus  infection  is  always  a  mixed 
infection,  and  that  the  way  must  be  prepared  for  the  tetanus 
bacillus  by  a  preceding  pathogenic  germ,  causing  a  septic  endo- 
metritis or  some  other  pathological  condition  along  the  birth- 
canal.  This  theory  is  not  supported  by  the  three  cases  under 
my  observation,  in  each  one  of  which  a  most  painstaking  post- 
mortem examination,  conducted  by  a  skilled  pathologist,  failed 
to  reveal  any  septic  lesion  of  the  birth-canal. 

The  disease  may  break  out  at  almost  any  time  after  confine- 

^  "  Ueber  Tetanus  Puerperalis,"  "Deutsche  med.  Wochenschr.,"  No.  14,  p. 
318,  1894.  Other  cases  have  been  recently  reported  by  Meinert,  "  Archiv  f. 
Gyn.,"  Bd.  xliv,  p.  381;  Maxwell,  "Jour.  Amer.  Med.  Association,"'  xxxiii,  p. 
224;   Irwin,  "N.  Y.  Med.  Jour.,"  p.  324,  1892. 


PUERPERAL    SEPSIS.  769 

ment,  but  usually  appears  within  the  first  two  weeks.^  It  runs 
a  varying  course,  sometimes  ending  fatally  within  a  few  days, 
in  other  cases  lasting  a  number  of  days  or  weeks  before  the 
symptoms  become  aggravated  enough  to  permit  of  a  diagnosis. 
The  fever  may  be  very  high,  may  be  quite  moderate,  or  may  be 
altogether  absent  until  just  before  death. 

The  prognosis  is  extremely  grave ;  the  mortality  may  be  put 
at  about  90  per  cent.^ 

A  curious  mistake  in  the  diagnosis  of  this  disease  has  been 
brought  to  my  notice  on  three  separate  occasions.  In  each  of 
these  cases  occurring  at  quite  long  intervals  of  time,  seen  each 
by  a  different  physician,  the  disease  was  taken  for  hysteria  and 
was  so  treated  for  a  number  of  days. 

The  treatment  consists  of  the  administration  of  huge  doses 
of  the  bromids^  and  of  chloral,  with  stimulants,  and  in  a  disin- 
fection of  the  birth-canal.  If  a  reliable  tetanus  antitoxin  can  be 
procured,  it  is  advisable  to  try  it.* 

Suppuration  of  the  Pelvic  Joints. — Any  of  the  pelvic  joints 
may  suppurate  by  the  extension  of  an  infectious  inflammation 
or  by  a  metastatic  infection.  The  symphysis  is,  however,  most 
often  affected,  usually  in  consequence  of  some  injury  during 
labor,  which  lessens  the  resisting  power  of  the  joint.  An  early 
diagnosis  of  suppuration  in  this  locality  should  be  made,  and  as 
soon  as  the  observ^er  can  convince  himself  that  the  joint  contains 
pus  it  should  be  freely  opened  and  thoroughly  drained. 

The  prognosis  is  fairly  good.  In  the  University  Maternity  we 
have  had  a  good  result  in  suppuration  of  both  sacro-iliac  joints. 

Ischiorectal  Abscess. — Suppuration  in  the  ischiorectal  fossa 
may  occur  in  consequence  of  injury  to  this  region  during  labor. 
I  have  one  patient  in  whom  an  ischiorectal  abscess  developed 
regularly  after  some  four  or  five  successive  confinements.  The 
diagnosis  of  the  condition  is  easy,  and  its  treatment  is  a  free 
evacuation  of  the  pus  and  good  drainage  of  the  abscess-cavity. 

The  Relation  of  Infectious  Fevers  to  Puerperal  Infection,  especially 
of  Erysipelas,  Diphtheria,  Scarlet  Fever,  and  Malaria. — A  woman 
after  confinement  is  more  susceptible  to  the  infectious  fevers  than 

1  Vinay  ("Du  tetanos  puerperal,"  "Archives  de  Tocol.,"  1892,  p.  791)  col- 
lected 106  cases — 47  after  abortion,  59  after  labor  at  term.  After  abortion  tlie  disease 
broke  out  in  21  cases  during  the  first  week  ;  in  16  during  the  second ;  after  labor  in 
19  cases  during  the  first  week  ;  in  23  during  the  second.  F.  B  Hancock  and  J.  C. 
Hirst  added  13  cases  to  Vinay's  statistics,  "University  Med.  Magazine,"  August, 
1897. 

2  Vinay  found  a  mortality  of  88.67  P^r  cent.  In  surgical  cases  the  mortality 
has  been  89.7  per  cent. 

■'  Camphor,  and  opium  are  also  advised. 

^  Baccelli's  method  may  also  be  tried,  the  subcutaneous  injection  of  large  doses 
of  carbolic  acid  in  weak  solution. 

49 


770 


PATHOLOGY  OF   THE   PUERPERIUM. 


she  is  at  other  times.  Her  lowered  vitality  and  perhaps  the 
reception  of  the  poisons  of  these  diseases  into  the  genital  tract 
make  the  period  of  incubation  shorter  and  the  disease  itself  more 
violent  in  its  manifestations  and  more  fatal  in  its  results.  Thus, 
measles,  a  disease  ordinarily  of  low  mortality,  is  much  more  danger- 
ous during  the  puerperium. 

It  is  therefore  incumbent  upon  the  practitioner  of  medicine 
to  abstain  from  obstetrical  work  altogether,  if  possible,  while  in 
attendance  upon  cases  of  exanthematous  fever  or  upon  diph- 
theria.    It  is  not   sufficient  for  the  physician  to  depend   alone 


Fig.  568. — Bilateral  ischiorectal  abscess,  slough  of  the  gluteal  muscles,  and  per- 
foration of  the  rectum  after  labor.  Cured  by  drainage  and  irrigation.  (Author's  case, 
Philadelphia  Hospital.      Patient  supposed  to  be  syphilitic.) 


upon  thorough  disinfection  of  his  hands  and  arms  in  such  cases  ; 
his  hair,  clothing,  skin,  and  breath  may  convey  the  contagion  to 
the  puerpera,  who  will  absorb  it,  perhaps,  not  only  by  the  ordi- 
nary channels,  as  by  the  throat  in  diphtheria,  but  also  by  the 
genital  tract  as  well. 

Cases  are  reported  in  which  a  recently  delivered  woman  had 
at  the  same  time  diphtheritic  exudate  containing  the  Klebs-Loffler 
bacillus  upon  the  pharyngeal  and  upon  the  vaginal  mucous 
membranes.  If  a  physician  can  not  escape  the  necessity  of  at- 
tending a  woman  in  child-birth  while  in  attendance  upon  conta- 
gious diseases,  he  should  take  a  full  bath,  should  rinse  his  mouth 


PUERPERAL   SEPSIS.  7/1 

and  brush  his  teeth  with  an  antiseptic  mouth- wash,  should  change 
his  clothing  throughout,  and  should  be  as  long  as  possible  in  the  open 
air  afterward  before  he  sees  his  parturient  patient,  in  addition  to  ob- 
serving a  careful  aseptic  technique  in  his  examinations  of  the  patient. 

Erysipelas. — The  connection  of  erysipelas  with  puerperal  in- 
fection may  be  dismissed  in  a  few  words.  Modern  bacteriologi- 
cal research  points  to  the  identity  of  the  streptococcus  pyogenes 
and  the  streptococcus  erysipelatis.  The  production  of  pus  and 
internal  inflammation  or  of  an  efflorescence  upon  the  skin  is  simply 
a  question  of  virulence  and  of  situation.  It  is  not  surprising, 
therefore,  to  hear  of  such  experiences  as  those  of  Winckel,  who 
has  found  germs  in  abscesses  of  the  pelvis  after  labor  that  on 
inoculation  produced  erysipelas,  and  who  has  seen  one  of  his 
nurses,  after  catheterizing  a  febrile  patient,  develop  erysipelas  of 
the  face  from  a  drop  of  the  lochial  discharge  that  splashed  upon 
her  nose. 

Other  clinical  facts  are  also  easily  explicable  by  the  identity 
of  the  pyogenic  and  of  the  erysipelatous  streptococci.  In  the 
course  of  puerperal  infection,  erysipelas  may  appear  upon  the 
labia  and  spread  thence  down  the  thighs  or  over  the  trunk.  If 
the  patient,  on  the  contrary,  contracts  erysipelas  in  some  portion 
of  the  body  remote  from  the  genitalia,  as  upon  the  breast  or 
face,  the  disease  may  run  its  ordinary  course  without  symptoms 
of  infection  of  the  genital  tract  and  without  great  danger  to  life  ; 
but  if  the  infection  spreads  to  the  genitalia  or  has  its  origin  there, 
the  danger  of  death  is  great. 

DipJitlicria. — The  connection  between  diphtheria  and  epi- 
demics of  puerperal  infection  has  been  demonstrated  beyond  a 
doubt  by  a  vast  amount  of  clinical  observation.  To  select  a 
single  exampl'e  out  of  many  :  One  of  my  young  friends  and 
former  students  lost  two  healthy  women  in  a  week  from  puer- 
peral sepsis  while  he  was  in  attendance  upon  a  child  with  diph- 
theria. 

He  had  never  had  a  serious  case  of  puerperal  infection  before, 
and  he  has  not  had  one  since.  The  Klebs-Loffler  bacillus  has 
been  found  in  two  cases  of  vaginal  exudate  under  my  notice  in 
Philadelphia.  As  already  stated,  the  mere  disinfection  of  the 
physician's  hands  and  arms  is  not  enough  to  protect  a  woman 
against  this  malignant  disease.  Complete  change  of  clothing, 
including  the  sjioes  ;  a  thorough  soap  and  hot-water  bath,  with 
scrubbing  of  the  hair,  face,  and  exposed  portions  of  the  body  ; 
brushing  of  the  teeth,  and  gargling  of  the  throat  with  an  anti- 
septic wash,  such  as  listerine,  and  a  purification  of  the  lungs  by 
prolonged  exposure  in  the  open  air,  are  necessary  ])recautions. 

Scarlet  Fc^z^e;-.— Contrary  to  the  opinion  expressed   by  some 


772  PATHOLOGY  OF   THE   PUERPERIUM. 

authorities,  scarlet  fever  in  the  puerperium  is  rare.  The  com- 
paratively frequent  occurrence  of  septic  erythemata  has  led  to 
the  erroneous  belief  that  scarlet  fever  is  a  common  cause  of  septic 
infection  after  child-birth.  The  same  rule  obtains  in  the  case  of 
scarlet  fever  in  the  puerperium  as  in  other  infectious  diseases  dur- 
ing that  period — namely,  the  woman  is  more  susceptible  to  con- 
tagion, the  period  of  incubation  is  shorter,  and  the  disease  is  more 
dangerous  than  at  other  times.  During  pregnancy  the  woman  is 
particularly  resistant  against  the  poison  of  scarlatina.  She  may 
carry  it  about  with  her  while  pregnant,  and  may  only  yield  to  it 
after  child-birth.  As  evidence  that  the  poison  of  scarlatina  finds 
an  entrance  into  the  body  through  the  mucous  membrane  of  the 
genital  tract,  it  is  interesting  to  observe  that  in  the  puerperium 
the  rash  is  more  marked  upon  the  lower  portion  of  the  body, 
and  that  the  throat  symptoms  may  be  entirely  absent  or  very 
mild. 

Malaria. — The  puerperal  state  excites  almost  surely  a  fresh 
outbreak  of  malaria  that  is  latent  in  the  system,  even  though  it 
has  been  dormant  for  years.  There  is  no  special  predisposition 
to  infection  during  the  puerperium. 

The  differential  diagnosis  of  malaria  and  sepsis  may  be  puz- 
zling at  first,  but  the  past  history  of  the  patient,  the  leukocyte 
count,  the  microscopic  examination  of  the  blood,  blood-cultures, 
cultures  of  the  lochia,  and  the  therapeutic  test  usually  suffice  to 
clear  up  all  doubt  in  twenty- four  hours.  To  be  on  the  safe  side  in 
doubtful  cases  it  is  wise  to  disinfect  the  genital  tract,  as  well  as  to 
administer  antimalarial  treatment. 


PART  VI. 
OBSTETRIC  OPERATIONS. 


CHAPTER  I. 

Aseptic  and  Operative  Technique. 

The  Hospital  Operating  Room. — The  requirements  for  a  mod- 
ern operating  room  differ  as  the  room  is  designed  simply  for  opera- 
tive work  or  for  instruction  of  students  in  addition.  In  the  former 
case  the  following  considerations  should  be  taken  into  account: 
The  floor  and  walls  are  made  of  non-absorbable,  easily  cleansed 
material.  For  the  former,  white  hexagonal  tiles,  and  for  the 
latter,  glass  wainscoting,  are  the  best.  The  room  should  be  heated 
to  90°  F.  There  should  be  no  draughts  of  hot  air  to  blow  dust 
about.  The  best  heating  apparatus  is  a  coil  of  heavy  nickel- 
plated  tubes  for  hot  water  or  steam.  The  floor  should  have  a  vent 
for  the  water  with  which  it  is  flushed. 

The  light  is  furnished  by  a  skylight  and  windows,  so  that  it  is 
both  vertical  and  horizontal.  The  light  should  be  from  the 
north.  The  cut  in  the  roof  and  wall  should  be  continuous,  the 
glass  in  the  wall  and  the  roof  having  no  intervening  structural  work 
except  light  iron  frames.  Small  hot-water  or  steam  pipes  should 
run  along  the  iron  frames  of  the  window  and  skylight,  to  pre- 
vent chilling  the  air  by  the  large  glass  surface,  the  creation  of 
draughts,  and  the  "sweating"  of  the  glass.  A  cluster  of  eight 
or  ten  incandescent  electric  lights  should  be  suspended  above  the 
operating  table,  and  there  should  be  one  or  more  plugs  in  the  wall 
for  the  attachment  of  hand  and  head  lights. 

The  sterihzing  outfit  should  comprise  two  autoclave  steriKzers, 
a  water  sterihzer,  an  instrument  sterihzer,  and  an  implement 
sterilizer  for  basins,  pitchers,  etc.  The  sterilizers  may  be  in  an 
adjoining  room,  but  it  is  more  convenient  to  have  them  in  the 
operating  room  itself,  if  possible,  in  recesses  out  of  the  way  and 
yet  accessible.  A  trough  should  be  provided  long  enough  for 
three  men  to  stand  in  front  of,  in  which  sterile  basins  are  placed 
for  the  hand  cleansing.  This  trougli  sliould  have  hot-  and  cold- 
water  spigots  with  pedal  stops,  although  tap  water  is  not  used 
for  the  hand  cleansing, 

773 


774 


OBSTETRIC   OPERATIONS. 


The  ordinary  furniture  of  an  operating  room — glass  cases  for 
dressings,  glass-top  tables,  basin  stands  and  basins,  enameled 
iron  stools,  apparatus  for  normal  salt  injection,  materials  for 
hypodermic  stimulation — is  naturally  required.  There  should  be 
a  transformer  or  a  transformer  and  a  motor,  as  the  electrical  current 
is  alternating  or  direct  for  electrically  heating  the  cautery  knife, 
the  electric  clamp,  and  the  electric  cautery.  The  instrument 
cases  and  instruments  should  be  kept  in  an  adjoining  room,  as 
they  may  be  rusted  by  the  moist  hot  air  of  the  operating  room. 

A  clinical  amphitheater  for  demonstrating  pelvic  and  ab- 
dominal surgery  to  medical  students  should  have  ample  floor 
space,  so  that  the  operator  and  his  assistants  shall  not  be  un- 


Fig.  569. — The  Rochester  sterilizer  for  dressings,  etc. 


comfortably  crowded,  and  to  provide  room  for  two  or  more  operat- 
ing tables  in  use  at  once.  In  the  limited  time  at  the  disposal 
of  the  teacher,  closing  the  abdominal  wound  should  be  relegated 
to  competent  assistants,  so  that  two  or  three  abdominal  or  pelvic 
operations  may  be  shown  in  the  hour. 

The  sterilizing  plant  should  be  in  view  of  the  students,  and 
they  should  also  witness  the  hand-cleansing  process,  day  after  day, 
so  that  it  may  be  thoroughly  familiar  to  them.  The  operator 
and  his  assistants  should  don  their  head  coverings,  gowns,  and 
gloves  before  the  students.  In  short,  the  whole  process  of  pre- 
paring for  an  operation  should  be  regularly  exhibited  until  at  the 
end  of  a  session  each  step  is  so  familiar  that  it  could  not  well  be 
forfjottcn. 


ASEPTIC  AND    OPERATIVE    TECHNIQUE. 


77S 


The  Private  House  Operating  Room. — In  a  private  house  the 
room  selected  for  an  operation  should  be  near  that  in  which  the 
patient  lies  in  bed.     For  an  abdominal  or  vaginal  section,  shorten- 


Fig-  57°- — The  author's  operating  table,  of  enameled  iron  with  inflated  air-cushion. 


Fig.  571.  —  Lilicntlmrs  portable  operatini;  table  in  its  case. 

ing  of  the  round  ligaments,  and  suspending  the  kidney,  the  furni- 
ture, carpets,  and  hangings  should  be  rcmo\-ed. 


776 


OBSTE  TRIG   OPERA  TIONS. 


The  floor  should  be  scrubbed  with  soap  and  water,  and  then 
mopped  with  a  sublimate  solution,  shortly  before  the  operation, 
so  that  it  shall  be  damp  and  no  dust  will  be  raised  by  walking 
over  it.  For  a  vaginal  operation  it  suf&ces  to  tack  over  the  carpet 
a  sheet  which  has  been  wrung  out  in  a  subhmate  solution,  but  is 
left  moist. 

The  basins  and  pitchers  are  boiled  in  a  large  clothes-boiler. 
The  dressings  and  ligature  material  are  sterihzed  either  in  the  cage 
of  a  hospital  autoclave,  which  is  transported  to  the  house  wrapped 


Fig.  572. — Lilienthal's  portable  operating  table,  set  up. 

in  double  sheets,  or  in  the  house  itself  in  a  Rochester  steam  steril- 
izer.^ A  large  quantity  of  boiling  water  is  on  hand  at  the  hour 
of  operation,  and  boiled  water  is  provided  in  pitchers  with  towels 
over  their  tops,  plainly  labeled  on  a  strip  of  rubber  adhesive  plaster, 
so  that  water  and  sublimate  solutions  shall  not  be  confused.  Two 
small  tables  from  the  household  furniture,  draped  with  sterile  sheets, 
suffice  for  the  instruments  and  pads.  Another  table,  similarly  pro- 
tected, is  needed  for  the  autoclave  cage  or  the  steam  steriKzer. 

1  The  l8-inch  size  oblong  sterilizer  can  be  packed  and  put  in  the  autoclave,  where 
it  is  sterilized  under  pressure.  It  is  packed  in  a  case,  transported  to  the  house,  and 
resterilized  just  before  the  operation. 


ASEPTIC  AND    OPERATIVE    TECHNIQUE. 


777 


The  operating  table  should  be  simple  in  construction,  light 
in  weight,  easily  moved  on  large  rollers,  with  a  quickly  and  easily 
managed  hinged  arrangement  for  the  Trendelenburg  posture. 
Supports  for  the  shoulders  are  provided  to  hold  a  patient  in  the 
Trendelenburg  posture.  An  air-cushion,  covering  almost  the  whole 
length  of  the  table,  is  useful,  as  it  saves  the  patient  a  great  part  of 
the  backache  usually  complained  of  after  operation  and  keeps  her 


Fig.  573- — Kitchen  table  draped  with  a  sheet  and  Edebohls'  leg   supports  attached. 


warmer  than  a  glass  or  iron  surface  would.  It  is  possible,  but  not 
advisable,  to  fill  the  cushion  with  hot  water.  There  is  danger  of 
burning  her  back  if  the  tem])erature  of  the  water  is  not  carefully 
regulated.  The  table  is  provided  with  the  upright  leg  supports  and 
stirrups  for  the  feet.  A  good  portable  table  is  a  great  convenience 
in  private  house  operations.  The  table  shown  in  figure  572  is  the 
most  satisfactory.  It  is  light  (28  pounds),  portable,  strong,  and  easily 
managed,  giving  the  various  postures  required  in  gynccic  surgery. 


77^ 


OBSTETRIC   OPERATIONS. 


For  plastic  operations  the  Edebohls  clamps  and  leg  supports, 
which  can  be  attached  to  any  kitchen  table,  are  a  cheap  and 
satisfactory  substitute  for  a  specially  constructed  operating  table. 
Leg-holders,  such  as  Robb's  and  Clover's,  are  not  so  convenient, 
and  it  is  difficult  to  keep  them  clean.  If  a  leg-holder  is  used,  one 
should  be  improvised  with  a  clean  sheet. 


Fig.  574. — Improvised  leg-holder  with  twisted  sheet. 


Hand  and  Skin  Cleansing.^ — There  is  no  known  method 
by  which  the  human  skin  can  be  made  sterile.  It  can  be  so  well 
cleansed,  however,  as  not  to  be  a  dangerous  source  of  infection 
unless  the  operator  has  contaminated  his  unprotected  hands  with 
some  particularly  virulent  micro-organism,  such  as  the  strepto- 
coccus of  purulent  peritonitis.  The  question  of  the  best  method 
of  hand  cleansing  is  not  now  such  an  anxious  one,  as  the  surgeon 
must  wear  rubber  gloves  uniformly,  no  matter  what  system  of  skin 
cleansing  he  uses,  and  should  cover  his  arms  with  a  long-sleeved 
gown.  The  insertion  of  the  bare  hand  in  a  wound  or  body  ca\'ity 
is  unjustifiable  in  the  light  of  our  present  knowledge.  But  the 
gloves  may  be  pricked  or  torn  during  an  operation,  so  that  the 
hands  under  them  must  be  made  as  clean  as  it  is  possible  to  get 
them.  The  skin  must  be  freed  of  all  superficial  epidermis  scales; 
the  sebaceous  matter  must  be  removed  not  only  from  the  surface, 
but  from  the  crypts  in  the  skin;  the  nails,  the  opposed  and  palmar 

1  See  "  Handereinigung,  Handedesinfektion,  uiid  Handeschutz,"  Haegler,  1900  ; 
and  "Beitriige  zur  liandedesinfektionsfrage,"  Schaeffer,  1902.  Also  "  Weitere, 
Beitrage  zur  Handedesinfektion,"  "  Monatsschr.  f.  Geb.  u.  Gyn.,"  Bd.  xix,  1904. 


ASEPTIC  AND    OPERATIVE    TECHNIQUE.  Jjg 

surfaces  of  the  fingers,  should  receive  particular  attention.  The 
metliod  should  be  as  simple  and  uncomplicated  as  is  consistent 
with  the  best  results. 

The  following  principles  of  skin  disinfection  must  be  remem- 
bered to  secure  the  best  results:  Mechanical  cleansing  is  better 
than  chemical  disinfection;  the  best  chemical  disinfectants  are 
chlorin  and  linsol. 

The  following  system  is  employed  by  the  author  because  he 
believes  it  to  be  efficient  and  not  too  complicated  and  because  the 
bacteriological  examinations  have  shown  as  sterile  a  condition  of 
the  skin  as  is  secured  by  any  method :  Three  sterile  basins,  three 
small  glass  dishes,  and  a  tub  (for  subhmate  solution)  are  provided. 
The  basins  are  for  the  hot  water,  the  glass  dishes  for  tincture  of 
green  soap.  Three  medicine  glasses,  each  with  2^  drams  of  linsol,^  are 
placed  near  the  trough  on  a  glass  table,  and  on  this  same  table  are 
two  flasks,  one  containing  alcohol,  the  other  acetic  acid,  f.5ij,  calcium 
chlorinate  3iv,  sterile  water,  Oij.  A  package  of  sterile  wash-rags 
is  placed  near  the  scrub-up  outfit  and  a  metal  powder-shaker,  filled 
with  grated  sandsoap  which  has  been  sterilized  in  the  autoclave, 
is  near  at  hand.  Six  brushes  are  sterilized  in  the  autoclave.  The 
three  basins,  each  with  a  small  glass  dish  of  tincture  of  green  soap 
beside  it,  are  placed  in  a  long  trough,  in  front  of  which  the  operator 
and  his  two  assistants  stand  side  by  side. 

The  nails  are  cut  short.  The  hands  and  arms  to  the  elbow  are 
scrubbed  for  ten  minutes  by  the  clock  in  the  following  manner :  The 
basins  are  put  in  a  row  in  the  trough  and  filled  with  sterile  water. 
A  sterile  wash-rag  dipped  in  the  water,  spread  out  on  the  physician's 
hand,  is  thickly  dusted  with  grated  sandsoap  by  the  nurse.  The 
physician  scrubs  his  hands  and  fingers  with  a  rotary  motion  of  the 
rag.  In  no  other  way  can  the  apposed  finger  surfaces  be  got  at 
so  well.  In  three  minutes  the  water  in  the  basins  is  changed. 
A  sterile  brush  is  taken,  dipped  into  the  glass  dish  containing  tinc- 
ture of  green  soap,  and  with  it  the  hands  and  arms  are  vigorously 
scrubbed.  In  three  minutes  the  water  is  again  changed,  and  this 
time  the  2\  drams  of  linsol  is  poured  into  the  basin,  making,  with  the 
water  in  it,  about  'k  per  cent,  solution.  The  hands  and  arms  are 
again  scrubbed  for  three  minutes,  making  nine  in  all.  The  basins 
are  emptied  and  filled  again  with  sterile  water;  the  hands  and  arms 
are  rinsed  for  a  minute.  Fresh  bruslies  are  then  taken  from  the 
autoclave  cage.  The  nurse  pours  on  the  hands,  arms,  and  brush 
alcohol  from  one  of  the  flasks;  the  arms  and  hands  are  scrubbed 

^  Linsol  is  an  improved  lysol  :  It  is  saponaceiais,  and  has  tiie  following  gennicidic 
power:  In  a  l  per  cent,  solution  it  destroyed  40,000,000  colon  bacilli  in  thirty 
seconds ;  58,000,000  staphylococci  and  2,000.000  streptococci  in  the  same  time 
(Philada.  Clin.  Laboratory).  By  mixing  e(|ual  parts  of  lin.  sapon.  moll,  and  liq. 
cresol.  com.  an  equivalent  antiseptic  may  be  obtained. 


78o 


OBSTETRIC   OPERATIONS. 


vigorously  for  a  minute;  then  the  chlorine  water  is  poured  in  the 
same  way  from  the  other  flask  and  another  minute  is  devoted  to  a 
scrub  with  it.  Finally,  the  hands  and  arms  are  immersed  for  a 
minute  or  two  in  a  i :  looo  subHmate  solution.  The  whole  process 
lasts  thirteen  to  fifteen  minutes.  One  cleansing  ordinarily  suffices 
for  an  operating  day.  Ten  to  twenty  operations  on  six  to  eight 
patients  in  succession  are  performed,  with  a  change  of  gowns  and 

gloves  after  each  operation.  If  a  glove 
is  pricked  and  a  finger  is  contaminated, 
a  two-minute  scrub  wath  a  i  per  cent, 
solution  of  Hnsol  suffices.  A  basin  of 
this  solution  and  a  supply  of  sterile 
brushes  are  ready  for  this  purpose. 

The  operating  suit  is  made  like  pa- 
jamas. It  is  sterile.  The  gown  must 
have  long  sleeves  to  the  wrist.  Canvas 
rubber-soled  shoes  should  be  worn.  The 
head  is  covered  by  a  cap;  the  breath 
filtered  through  the  Vienna  operating, 
mask.  The  hands  are  covered  with 
sterile  gloves.  This  is  the  author's 
technic  for  major  surgery.  For  minor 
operations  and  obstetrical  examinations 
a  five- minute  scrub  with  tincture  of 
green  soap  and  hot  water,  followed  by 
alcohol,  and  a  rinse  in  sublimate  solu- 
tion is  sufficient.  The  gown,  cap,  and 
mask  are  omitted. 

In  sterilizing  gloves  they  should  be 
well  powdered  with  talcum  powder, 
folded  between  layers  of  gauze,  and 
further  protected  by  muslin.  They 
should  be  laid  out  flat  in  the  autoclave, 
sterihzed,  and  put  on  dry.  For  obstet- 
rical operations  necessitating  deep  inser- 
tion of  the  hand  in  the  uterus,  long 
gauntlet  gloves  must  be  worn.  It  is 
difficult  to  put  them  on  dry,  so  they  are  boiled  and  put  on  by  pour- 
ing a  little  sterile  glycerin  into  them. 

The  Preparation  of  the  Patient  for  an  Abdominal  Section. 
— The  Afternoon  before  Operation ;  Skin  Cleansing.- — Prepare 
rubber  gloves  by  wrapping  in  gauze  and  dry  sterilization.  Clip 
pubic  hair  with  clipper  and  shave  with  a  safety  razor.  Sterilize 
the  following  articles  for  forty-five  minutes  at  240°  F.  :  Two 
hand   brushes  for  nurse;  two  soft-bristle  brushes  for  patient;  ab- 


Fig.  575. — The  surgeon's  dress, 
with  Vienna  operating  mask. 


ASEPTIC  AND    OPERATIVE    TECHNIQUE. 


781 


sorbent  cotton;  four  small  sheets;  one-half  dozen  towels;  gauze, 
unmedicated ;  gauze  pad;  binder;  long-sleeved  gown. 

The  nurse  who  cleanses  the  abdomen  must  prepare  her  hands 
and  arms  as  though  about  to  operate,  namely:  Cut  nails  short; 
scrub  hands  and  arms  with  brush,  hot  water,  and  tincture  of 
green  soap  for  ten  minutes,  with  four  changes  of  sterile  water  in 
sterile  basin;  clean  nails  with  boiled  nail-file;  with  fresh  brush 
scrub  hands  and  arms  with  alcohol;  immerse  hands  and  arms  in 
bichlorid  solution  (i :  1000)  for  two  minutes.  Then  put  on  the 
long-sleeved  gown  and  gloves. 

The  abdomen,  from  the  ensiform  to  symphysis  and  from  flank  to 
flank  and  one-third  the  way  down  the  thighs,  must  be  scrubbed 


Fig.  576. — Gauze  pad  for  patient's  abdomen,  extending  part  way  down  the  thighs. 


with  soft-bristle  brush,  tincture  of  green  soap,  and  hot  water  thor- 
oughly (for  ten  minutes  by  the  watch,  with  four  changes  of  sterile 
water),  paying  special  attention  to  navel  and  to  pubic  regions. 
Scrub  thoroughly  with  alcohol  with  the  second  sterile  soft-bristle 
brush.  Cover  the  abdomen  with  the  sterile  gauze  pad  and  put 
on  the  binder. 

Morning  0}  iJie  Opera/ion. — Give  2  ounces  of  clear  beef-tea 
at  7  o'clock;  give  enema  of  pint  of  soaj)suds,  i  dram  of  turpentine. 
Hands  of  nurse  cleansed  as  described  above.  Articles  rcsteril- 
ized  as  described  above.  Same  cleansing  of  abdomen  rej^eated 
as  described  above,  but,  in  addition:  Before  alcoliol  scrub1)ing, 
scrub  abdomen  with  i  per  cent,  linsol  solution;  wring  out  the  large 


782  OBSTETRIC   OPERATIONS. 

Sterile  gauze  pad  in  i  per  cent,  formalin  solution,  and  cover  the 
abdomen  with  it;  put  over  it  a  thick  layer  of  sterile  cotton;  apply 
binder,  Catheterize  the  woman  just  before  anesthetization  with 
sterile  glass  catheter  (in  all  cases  of  abdominal  tumor  the  long  silk 
or  rubber  catheter/  previously  boiled,  to  be  used)  in  aseptic  manner. 
Give  vaginal  douche,  i  quart  of  i :  4000  sublimate  solution,  fol- 
lowed by  a  little  sterile  water.  Pack  the  vagina  with  sterile  gauze. 
Packing  always  to  be  removed  in  twenty-four  hours  at  most  or 
directly  after  the  operation. 

The  patient  is  dressed  for  the  operation  in  Canton  flannel 
leggings  covering  the  feet  and  reaching  to  the  hips,  and  in  a  short 
gown,  open  down  the  back,  reaching  only  to  the  hips. 

The  Preparation  of  the  Patient  for  a  Plastic  or  any  Vaginal 
Operation. — Evening  Be] ore. — Sulfonal  or  trional,  gr.  xv,  if  she  is 
sleepless  or  nervous.  Epsom  salt,  one-half  ounce  in  tumblerful  of 
water  at  9  o'clock. 

Morning  of  Operation. — Cup  of  beef-tea  at  7  o'clock.  Enema 
of  soapsuds  and  turpentine.  Irrigation  of  lower  bowel  by  re- 
peated injections  until  it  is  completely  emptied.  Wash  pubis  and 
labia  with  gloved  hands,  using  tincture  of  green  soap,  hot  water, 
sublimate  solution,  and  pledgets  of  sterile  cotton.  Shave  pubis 
and  labia.  Wash  out  vagina  with  tincture  of  green  soap  and 
pledgets  of  cotton.  Give  douche  of  i :  4000  bichlorid  solution 
followed  by  sterile  water  ;  tampon  vagina  with  sterile  gauze. 
Catheterize  patient  just  before  anesthetization  with  sterile  glass 
catheter  in  aseptic  manner. 

//  a  vaginal  tampon  is  inserted  after  an  operation,  it  must 
never  he  left  in  longer  than  twenty-four  hours,  except  by  order  of 
the  chief.  Douches  after  a  plastic  operation  to  be  given  only  by 
order  of  the  chief.  The  number  of  stitches  to  be  removed  must 
invariably  be  noted  on  the  chart. 

Ligatures  and  Sutures. — Catgut,  silkworm  gut,  and  Pagen- 
stecher's  celloidin  thread  are  the  only  materials  employed.  The 
catgut  is  in  three  sizes,  o,  i,  and  3.  Sizes  o  and  i  are  used  for  con- 
tinuous sutures;  3  for  some  of  the  interrupted  sutures,  as  in  trache- 
lorrhaphy, and  for  ligatures.  The  finest  size  only  of  celloidin 
thread  is  used. 

The  cehoidin  thread  is  rolled  on  reels,  put  in  glass  tubes  stop- 
pered with  cotton,  and  given  fractional  sterilization  on  three  suc- 
cessive days  in  the  autocla^•e.     The  silkworm  gut  is  boiled. 

The  catgut  is  prepared  as  follows : 

Twelve  hours  in  benzine. 

Twelve  hours  between  sterile  towels. 

iln  case  of  abdominal  tumor  the  bladder  is  sometinies  sacculated  or  lifted  high, 
into  the  abdomen,  and  a  short  catheter  will  not  evacuate  it. 


ASEPTIC  AND    OPERATIVE    TECHNIQUE.  783 

One  hour  in  formalin  (5  per  cent.). 
Twelve  hours  in  chromicizing  fluid. 

Formula  for  Chromicizing  Fluid  : 

Potassii  bichromate,  1. 5  parts 

Acidi  carbolici,  10        '• 

Glycerin,  lo        " 

Aq.  destii.,  480        " 

Eighteen  to  twenty-four  hours  in  sterile  water  (first  six  hours 
under  running  sterile  water). 

Two  nurses  then  scrub  up  as  if  for  operation,  and  use  long-sleeve 
gown  and  rubber  gloves. 

The  catgut  is  tied  one  end  to  another  and  wound  firmly  on 
sterile  metal  cylinders,  then  stretched  on  a  wooden  frame  which 
has  been  covered  with  sterile  bandage. 

The  table  the  catgut  is  prepared  on  should  be  covered  with 
sterile  rubber  sheeting,  and  over  this  a  plain  sterile  sheet. 

After  the  catgut  is  stretched  on  the  frame  it  should  dry  for  at 
least  four  days,  then  cut  in  lengths  for  sutures  (about  36  inches). 
It  is  then  wound  on  glass  spools  about  6  inches  long,  five  sutures 
of  fine  on  one  and  five  of  heavy  on  the  other.  The  spool  is  then  put 
in  a  metal  cyhnder  with  screw  cap,  and  a  solution  of  alcohol,  9  parts, 
glycerin,  i  part,  is  poured  in.  The  cap  is  then  fastened  on  tightly 
and  put  in  a  sterilizer.  It  is  then  sterilized  in  a  hot-air  oven  for 
one  hour  at  300°  F. 

For  the  surgeon  without  hospital  facilities  the  Claudius  iodine 
gut  is  recommended — namely,  gut  soaked  for  eight  days  in  a  solu- 
tion of  \  part  iodine,  i  part  iodide  of  potassium,  and  100  parts 
water.  The  original  Claudius  solution  of  i  per  cent,  iodine  makes 
the  gut  too  brittle. 

Anesthesia. — Nitrous  oxide  gas  followed  by  ether  on  gauze  by 
the  drop  method  is  the  routine  system  recommended.  Pregnant 
women,  however,  should  ne\-er  be  given  nitrous  oxide  gas.  It 
asphyxiates  the  fetus.  For  all  operations  on  pregnant  and  par- 
turient women  chloral  chloroform  is  used.  Chloroform  is  also 
recommended  in  case  of  any  kidney  or  lung  complication;  for 
brief  anesthetizations  and  for  air  distention  cystoscopy  with  the 
patient  in  an  exaggerated  Trendelenburg  position. 

Instruments. — The  particular  instruments  required  in  the 
various  operations  are  described  in  the  aijjjropriale  i)lace.  All 
metal  instruments  are  sterilized  by  boiling  in  water  for  at  least 
twenty  minutes,  except  the  knives,  which  are  kept  immersed  in  a 
5  per  cent,  solution  of  carbolic  acid  in  alcohol  to  preserve  a  keen 
cutting  edge.  The  instruments  common  to  all  surgical  operations, 
such  as  hemostats,  should  be  j^rovidcd  in  an  invarialjle  number, 
and  all  should   be  accounted  for  before  closing  a  body  cavity. 


784  OBSTETRIC   OPERATIONS. 

Each  operator  will  consult  his  own  convenience  or  fancy  in  the 
arrangement  of  his  instruments  for  use,  but  it  is  a  safe  plan  to 
keep  them  in  the  receptacle  in  which  they  have  been  boiled,  which, 
therefore,  should  be  ample  in  size  and  provided  with  compart- 
ments, each  containing  instruments  of  one  kind. 


CHAPTER   11. 


The  Artificial  Dilatation  of  the  Cervical  Canal  and  the  Operations 
to  Deliver  the  Embryo  and  Fettis. 

THE  ARTIFICIAL  DILATATION  OF  THE  CERVICAL  CANAL. 

It  is  necessary  to  dilate  the  cervical  canal  artificially  for  mechan- 
ical dysmenorrhea;  for  sterility;  to  explore  the  interior  of  the  uterus 
with  the  finger  and  with  instruments;  in  cases  of  rigidity  of  the 
cervix,  or  when  it  is  desired  to  hasten  labor  for  any  purpose. 
The  OS  may  be  dilated  by  rubber  bags,  by  graduated  bougies, 
by  the  fingers,  by  pulling  the  head  down  with  forceps,  by  taking 
hold  upon  a  foot  or  leg  in  a  breech  presentation,  by  discission  of 
the  cervix,  by  multiple  incisions,  or  by  branched  dilators. 

Hydrostatic  Dilatation. — For  this  purpose  two  kinds  of  rub- 
ber bags  are  employed.  One  of  a  cone  shape  (Voorhees)  and  of 
graduated  sizes,  the  other  consisting  of  two  bags,  one  within  the 
other ;  the  first  like  Voorhees'  bag,  the  other  the  shape  of  the  birth- 
canal  at  the  moment  of  its  full  dilatation  (Pom.eroy's  bag,  Fig.  577). 
To  insert  one  of  these  rubber  bags,  it  is  rolled  upon  itself,  grasped 
in  an  Emmet  curetting  forceps,  or  with  the  forceps  that  comes 
with  the  Champetier  de  Ribes  bag,  well  smeared  with  sterile 
glycerin,  and  passed  into  the  cervical  canal,  so  that  it  enters  the  lower 
uterine  segment.  The  tube  is  then  attached  to  the  nozzle  of  an 
aseptic  graduated  metal  syringe  and  the  bag  is  distended  with 
water.  It  is  well  to  test  the  capacity  of  each  bag  outside  the 
woman's  body  to  avoid  overdistention  and  the  danger  of  bursting. 
When  the  bag  is  filled,  the  rubber  tube  attached  to  it  is  clipped 
with  a  hemostat,  a  knot  is  tied  in  the  tube  below  the  hemostat,  the 
latter  is  removed,  and  the  tube  is  tucked  into  the  vagina,  which  is 
then  packed  with  gauze.  Each  of  the  progressively  larger  bags 
is  inserted  in  the  same  manner,  and  allowed  to  remain  in  place 
from  fifteen  minutes  to  several  hours,  according  to  the  time  at 
one's  disposal.  The  tube  may  be  ])ulled  upon  by  the  nurse  or 
attendant  every  two  to  five  minutes  for  about  a  minute  at  a  time 


ARTIFICIAL    DILATATION   OF   THE    CERVICAL    CANAL.     785 

to  hasten  the  dilatation  of  the  cervix,  in  which  case  the  packing 
may  be  removed  from  the  vagina  and  the  tube  be  left  hanging  out. 
Pomeroy's  bag  is  rolled  into  as  small  a  compass  as  possible,  grasped 


1 

Fig.  577. — Pomeroy's  bag  dis- 
tended with  water. 


Fig.  578. — Pomeroy's  bag  collapsed,  rolled  on 
itself,  and  grasped  by  the  Champetier  de  Ribes 
forceps. 


with  the  Champetier  de  Ribes  forceps,  well  anointed  with  sterile 
glycerin,  and  inserted  into  the  lower  uterine  segment,  so  that  the 


579. — Aseptic  metal  piston  syringe. 

internal  bag  when  dilated  will  be  caught  by  the  cervix  and  will  not 
slip  out.     The  internal  bag  is  first  dilated,  then  the  external  bag. 
The  instrument  is  exceedingly  efficient  in  multiijara,  the  whole 
50 


jm 


OBSTE  TRIG   OPERA  TIONS. 


birth-canal  being  completely  dilated  in  little  more  than  an  hour. 
The  Champetier  de  Ribes  bag  (Fig.  580)  is  clumsy  and  is  not  much 
used  in  America.     Barnes's  bags  have  become  obsolete. 


Fig.  580. — Champetier  de  Ribes'  bag  :   A,  inflated ;  B,  folded  for  mtioduction  into 

the  uterus. 


Fig.  581. — Voorhees"  bag. 


Manual  Methods. — The  best  manual  methods  for  the  dilata- 
tion of  the  OS  are  illustrated  in  figures  582,  588-593.  In  Harris' 
method  the  forefinger  and  thumb,  and  then  the  other  fingers  of 
the  hand,  are  successively  inserted,  the  thumb  and  the  fingers  being 
spread  apart  as  v/idely  as  possible.  In  Edgar's  method  the 
dilatation  is  begun  by  branched  dilators  and  is  completed  by  the 
powerful  action  of  the  first  two  fingers  of  both  hands.  By  this 
means  very  rapid  dilatation  of  the  os  is  possible;  the  manual 
method,  therefore,  is  recommended  in  cases  of  greatest  haste,  in 
which  it  is  only  desired  to  secure  enough  dilatation  to  make  the 
forcible  extraction  of  the  child  possible. 


ARTIFICIAL    DILATATION   OF   THE    CERVICAL    CANAL.     J^y 

Instrumental  Dilatation. — For  the  non-pregnant  uterus 
there  are  two-  and  four-branched  dilators  and  the  metranoikter  of 
Schatz  and  the  author.  Two  sizes  of  a  two-branched  dilator  are 
required,  a  light  and  a  strong.     For  the  former,  the  Baer  is  recom- 


Fig.  582. — Method  of  performing  rapid  manual  dilatation  of  the  os  uteri :  I,  Posi- 
tion of  fingers  in  the  beginning  of  manual  or  digital  dilatation  of  the  cervix  uteri,  first 
position;  2,  showing  limit  of  dilatation  in  the  lirst  position;  3,  second  position;  4, 
showing  limit  of  dilatation  in  the  second  position  ;  5,  third  position  ;  6,  limit  of  dila- 
tation in  the  third  position;  7,  fourth  position;  8,  limit  of  dilatation  in  the  fourth 
position;    9,  fifth  jiosition;    lo,  sixth  position  (Harris). 


mended;  for  the  latter,  the  Wathen's.  As  the  foiir-l)rantlK'(1  ])rin- 
ciple  is  su])erior  to  the  two,  which  only  dilates  in  one  direction, 
it  is  necessary  to  have  a  good  four-branched  dilator  for  a  tiiorough 
dilatation  of  the  cervix.  The  best  is  the  Cle\'eland  model  (Fig.  583). 
Moreover,  to  effectively  dilate  the  cervix  the  dilatation  must  con- 


y88 


OBS  TE  TRIG   OPERA  TIONS. 


tinue  a  considerable  time.  To  use  dilators  for  twenty  minutes,  as 
is  commonly  done,  is  often  useless,  the  cervix  recontracting  in  a  few 
hours.  Hence,  mechanical  dilatation  for  dysmenorrhea  and  steril- 
ity has  often  been  disappointing.  Schatz  devised  a  dilator(Fig.  585) 
for  retention  within  the  uterus  for  twenty-four  hours  which  gives 
much  more  satisfactory  results  than  the  temporary  dilatation  usually 


Fig-  583- — Cleveland's  dilator. 


Fig.  ^84.- 


-Author's  double  tenacula 
for  the  cervix. 


employed,  and  the  author  has  made  the  instrument  more  effective 
by  converting  it  into  a  four-branched  one.  By  thoroughly  dilating 
the  cervix  with  the  dilators  in  ordinary  use,  including  Cleveland's, 
by  a  curettage  with  Sims'  and  Martin's  curettes,  and  by  leaving, 
if  possible,  the  four-branched  metranoikter  or,  if  not,  the  two- 
branched  metranoikler  in  the  uterus  for  twenty-four  hours,  the 
percentage  of  cures  in  mechanical  dysmenorrhea  and  sterility  can 


ARTIFICIAL    DILATATION   OF   THE    CERVICAL    CANAL.     789 

be  more  than  doubled.^  Wylie  has  invented  a  "drain"  to  accom- 
plish the  same  purpose,  but  it  must  remain  in  the  uterine  cavity 
some  days,  does  not  dilate  the  cervical  canal  so  widely,  and  causes 
by  its  long  retention  an  infection  of  the  endometrium,  which  may 


Ficr.    585. — Schatz's    metranoikter.       The    four-bladed    instrument    is    the    autlior's 

modification. 


spread  to  the  tubes.     It  is,  therefore,  not  to  be  recommended. 
The  technic  of   dilatation  of  the   cervix  is  as  follows:  k\\  Au- 

'  A  virgin's  vagina  will  not  accommodate  the  fdur-hranched  dilator.  I  iiave  used 
the  metranoikter  over  four  years  in  more  than  150  cases,  with  the  results  stated  in  the 
text. 


790 


OBS  TE  TRIG   OPERA  TIONS. 


yard's  speculum  is  inserted;  the  anterior  lip  of  the  cervix  is 
seized  with  the  author's  double  tenaculum  and  pulled  down. 
The  two-branched  dilators,  first  the  light,  and  then  the  strong, 
are  inserted  and  separated  to  an  inch  and  a  quarter  on  the  scale; 
the  Cleveland  dilator  is  next  inserted  and  opened  to  70  or  90  mm. 
(circumference)  on  the  scale;  the  uterus  is  then  curetted  with  a 
Sims'  curette,  all  four  walls  being  scraped  several  times  in  succes 
sion.     A  Martin's  curette  is  next  used  to  curette  the  fundus  and 


Fig.   586. — J.   C.  Hirst's  dilator  for  the  pregnant  uterus  (modified  from  Gau  and 

Norris). 


cornua.  The  uterus  is  washed  out  with  a  two-way  catheter. 
The  metranoikter  is  inserted,  the  vagina  packed  with  gauze; 
10  per  cent,  of  the  patients  require  morphin.  The  metranoikter 
is  removed  in  twenty-four  hours  and  the  uterine  cavity  is  again 
washed  out  with  the  Fritsch-Bozeman  two-way  catheter. 

In  Ihe  pregnant  uterus,  if  the  os  is  already  about  the  size  of  a  dollar, 
and  it  becomes  necessary  to  deliver  the  child  rajjidly,  forceps  may  be 
applied  to  the  head  and  strong  traction  made.    The  cervix  will  either 


ARTIFICIAL   DILATATION  OF   THE    CERVICAL    CAAAL.     79 1 

stretch  or  tear,  and  it  is  thus  possible  to  extract  a  child  in  a  very  few 
minutes  when  there  is  urgent  need  for  rapid  delivery.  Several  two- 
or  more  bladed  instruments  have  been  devised  to  dilate  the  cervix 
of  a  pregnant  or  parturient  woman.  The  most  generally  useful 
one  is  the  modified  Gau  dilator  of  J.  C.  Hirst  (Fig.  586).  Bossi's^ 
dilator  was  first  described  in  1891  (Fig.  587),  but  was  not  generally 


Fig.  587- — Bossi's  dilator,  closed  and  opened.     The  expanded  tips  are  removable, 
so  that  the  instrument  may  be  inserted  in  an  undilated  os. 


adopted  till  Leopold  recommended  it  ten  years  later.  It  is  a  power- 
ful instrument  for  the  dilatation  of  the  gravid  or  parturient  cervix. 
If  the  blades  are  gradually  dilated  up  to  5  or  6  cm.  on  the  scale, 
there  is  little  or  no  risk  of  injury.  Rapid  and  complete  dilatation 
with  this  powerful  instrument  is  sure  to  be  followed  by  extensive 
injury.     It  is  best  to  dilate  to  5  or  6  cm. ;  next  to  insert  the  largest 

1  "  Sulla  Dilatazione  rapida  della  Bocca  Uterina  col   Dilatore    Bossi,"   "  Clinica 
Obstetrica,"  Anno  iv,  fasc.  vi-vii,  1902. 


792 


OBSTETRIC  OPERATIONS. 


Fig.  588. — Bimanual  dilatation  of  the  parturient  os.     Os  two-thirds  dilated.     Entire 
effacement  of  internal  os  (Edgar). 


Fig.  589. — Bimanual  dilatation  of  the  parturient  os.    External  view,  showing  position 

of  hands  (Edsar). 


ARTIFICIAL  DILATATIOX  OF  THE  CERVICAL  CAiVAL.     793. 


Fig.  590. — Bimanual  dilatation  of  the  parturient  os.  Os  admits  two  fingers. 
Vaginal  and  supravaginal  portions  of  the  cervix  present ;  commencing  shortening  of 
the  cervical  canal  (Edgar). 


Fig.  591. — Bimanual  dilatation  of  the  parturient  os.     Os  one-half  dilated.       Lateral 
position  of  the  hands  (Edgar). 


794 


OBSTETRIC  OPERATIONS. 


Fig.  592. — Instrumental  dilatation  of  parturient  os,  preparatory  to  further  manual 

dilatation  (Edgar). 


Fig.  593. — Digital  dilatation  of  the  parturient  os.     Os  admits  one  finger.     Vaginal 
and  supravaginal  portions  of  the  cervix  present  (Edgar). 


ARTIFICIAL    DILATATION   OF   THE    CERVICAL    CANAL.     795 

size  Voorhees'  bag  ;  then  to  apply  forceps  or  to  perform  ver- 
sion. The  cervical  canal  may  be  dilated  by  inserting  graduated 
bougies  from  the  size  of  a  small  lead-pencil  up  to  the  size  of 
one's  wrist  or  forearm  (Hegar).     This  is  an  effective  method,  but 


Fig.  594- — Hegar's  dilators  or  bougies. 

it  requires  a  number  of  bougies  which  are  scarcely  ever  carried 
about  by  any  obstetrician,  and  it  is,  therefore,  only  available  in  a 
well-equipped  obstetrical  hospital.  In  fifteen  to  twenty  minutes 
by  this  plan,  in  a  multipara,  the  os  may  be  almost  fully  dilated,  or 
sufficiently  at  least  to  permit  the  extraction  of  the  child  by  forceps 
if  the  head  presents,  or  by  drawing  down  a  leg  in  a  breech  pres- 
entation. 

Incisions. — In  the  non- pregnant  uterus  the  cervix  may  be 
separated  from  the  vagina  and  bladder  by  a  T-shaped  incision 
in  the  anterior  vaginal  vault,  and  then  cut  in  the  median  line  beyond 
the  internal  os,  thus  permitting  the  insertion  of  the  forefinger  to 
explore  the  uterus  or  obtaining  room  to  remove  an  intra-uterine 
growth,  such  as  a  myoma. 

In  the  pregnant  uterus,  Diihrssen  introduced  incisions  through 
the  cervix  to  the  vaginal  vault. ^  It  is  to  be  recommended  if  there 
is  need  for  the  utmost  rapidity  in  the  extraction  of  the  child.  If 
the  head  presents,  it  is  best  to  apply  forceps  to  pull  it  firmly  down 
against  the  cervix,  and  then,  with  scissors  or  a  blunt-pointed  bis- 
toury, to  cut  the  cervix  in  one,  two,  or  as  many  as  four  places,  until 
the  child  can  be  dragged  through  the  cervical  canal.  It  is  necessary 
afterward  to  suture  the  incisions,  which  bleed  profusely  for  a  time 
at  least.  If  the  patient's  condition  is  serious,  it  may  be  sufficient 
to  place  one  suture  in  the  upper  angle  of  each  incision.  This  checks 
the  hemorrhage  sufficiently  and  ])romotes,  occasionally,  llie  enlire 
repair  of  the  injury. 

Vaginal  Cesarean  Section  or  Anterior  Vaginal  Hysterot= 
omy. — Diihrssen  elaborated  his  original  plan  of  mullii)lc  reej) 
incisions  in  the  cervix  by  proposing  the  transN'crse  incision  of  the 
anterior  vaginal  vault,  a  longitudinal  section  of  the  vagina,  sepa- 
rating the  bladder  completely  from  the  cer\-ix  and  vagina,  if 
necessary,  opening  the  peritoneal  cavity,  pulling  down  the  cervix 
by  strong  double  tenacula,  splitting  the  anterior  lip  and  the  lo\\cr 
uterine  segment  in  the  middle  line  till  sufficient   space  is  gained 

1  "  Wiener.  Med.  Picsse,"  xxxi,  ^iZ- 


796 


OBSTETRIC   OPERATIONS. 


Fig.  ^g^. — Vaginal   incisions  for  vaginal  Fig.  596. — Cutting  the   cervix  and,  if 

Caesarean  section.  necessary,    the    lower   uterine    segment 

with  scissors  in  the  median  line,  ante- 
riorly, after  stripping  back  the  bladder. 


Fig-  597- — The  two-tier  suture  of  cat- 
gut to  close  the  cervical  wound. 


Fig.  598. — The  vaginal  wounds  closed  by 
interrupted  sutures. 


INDUCTION   OF  ABORTION  797 

to  deliver  a  full-term  child.  This  is  the  quickest  means  of  deliv- 
ering a  woman,  and  has,  in  selected  cases,  decided  advantages. 
Diihrssen  enthusiastically  recommends  it  as  the  first  step  in  the 
treatment  of  eclampsia.  The  author  has  employed  it,  but  would 
only  recommend  it  if  the  quickest  delivery  possible  is  essential. 
Slower  dilatation  of  the  cervix  by  the  hands,  bags,  or  Bossi's  dilators 
is  safer  and  less  troublesome,  if  there  is  no  urgent  necessity  for  im- 
mediate delivery.  The  wound  in  the  lower  uterine  segment  and 
cervix  is  sutured  with  a  tier  suture  of  durable  catgut;  the  anterior 
vaginal  vault  is  closed  with  interrupted  sutures  and-  gauze  drainage 
is  employed  for  four  days  or  more.  Hemorrhage  during  the  opera- 
tion is  controlled  by  forcibly  pulling  down  the  cervix.^ 

If  the  patient  is  a  primipara,  it  is  necessary  to  precede  the 
section  of  the  vagina  and  cervix  anteriorly  by  a  Schuchard's  sec- 
tion of  the  vagina  posteriorly;  that  is,  a  deep  incision  in  the  left 
posterior  vaginal  sulcus  and  through  the  perineum. 

INDUCTION   OF   ABORTION 

By  the  induction  of  abortion  is  meant  the  interruption  of  preg- 
nancy bejore  the  viability  of  the  child — that  is,  prior  to  the  sixth 
month  of  pregnancy. 

Indications. — The  induction  of  abortion  should  be  undertaken 
as  reluctantly  as  one  would  commit  justifiable  homicide.  If, 
in  the  course  of  pregnancy,  some  disease  arises  as  a  direct  con- 
sequence of  gestation,  or  if  a  woman  suffering  from  disease  is 
made  much  worse  by  the  existence  of  pregnancy,  and  if  her  life 
is  distinctly  endangered  in  consequence,  it  is  not  only  justifiable, 
but  it  is  the  physician's  duty  to  terminate  gestation,  and  thus  save 
one  life,  and  that  the  more  valuable  of  the  two,  instead  of  sacri- 
ficing both  mother  and  fetus.  The  following  conditions  occasion- 
ally furnish  a  justifiable  indication  for  the  induction  of  abortion. 

Pathological  Vomiting. — When  all  the  remedies  for  this  con- 
dition have  been  conscientiously  and  carefully  tried  without 
avail,  when  rectal  alimentation  has  been  continued  for  a  week  or 
ten  days  without  marked  imj^rovement  in  the  woman's  condition, 
and  it  is  evident  that  she  is  in  danger  of  death  if  her  pregnancy 
continues,  the  induction  of  abortion  for  uncontrollable  A-omiting 
is  justifiable. 

Toxemia,  Albuminuria,  and  Kidney  Breakdoicn. — If  ominous 
symptoms  appear,  such  as  jjrogressive  edema,  persistent  headaclie, 

'  Diihrssen,  "  Zeitschr.  f.  (id),  u.  C]yn.,"  Bd.  xxiii;  "Centralbl.  f.  Gyn.,"  No.  7, 
1S92  ;  "Arch.  f.  Ciyn.,"  Ikl.  xlii  and  xliii;  "  Berliner  klin.  Wocliensclir,,'"  No.  27, 
1892;  "  Der  Vaginal  e  Kaiserschnitt,''  1896;  "Arch.  f.  Gyn.,"  Bd.  Ixi  ;  "  Eklamp- 
sie,"  in  v.  Winckel's  "  Handbuch,"  Bd.  IT',  1905.  I/>id.,  Bd.  Ill-',  1906.  in  which 
Acconci's  claim  to  priority  is  discussed. 


798  OBSTETRIC   OPERATIONS. 

steady  or  rapid  increase  in  the  amount  of  albumen,  sudden  dimi- 
nution in  the  quantity  of  urine,  casts  in  great  number  in  the  urine, 
and  f aihng  vision,  in  spite  of  careful  dietetic  and  medicinal  manage- 
ment, the  induction  of  abortion  is  called  for. 

Death  0]  the  Embryo  or  Fetus. — If  it  can  be  demonstrated 
that  the  embryo  or  fetus  is  dead  within  the  uterus,  its  removal  is  de- 
sirable ;  but  it  must  be  remembered  that  the  signs  of  fetal  death  are 
difficult  to  ehcit,  and  that  a  certain  diagnosis  can  be  made  onh'  after 
an  observation  extending  over  some  days  or  weeks,  unless  the 
membranes  are  ruptured  and  the  fetal  body  has  begun  to  putrefy. 

Certain  Intra-iitcrine  Diseases. — As  pointed  out  in  the  section 
on  Intra-uterine  Diseases,  acute  hydramnios  and  cystic  degenera- 
tion of  the  chorion  villi  may  call  for  the  induction  of  abortion. 

Uterine  Hemorrhage. — Uterine  hemorrhage,  from  placenta 
praevia  or  from  the  detachment  of  an  abnormally  situated  pla- 
centa, may  be  so  profuse  or  so  long  continued  as  to  demand 
the  evacuation  of  the  womb  early  in  pregnancy. 

Displacement  of  the  Gravid  Uterus. — Retroflexion,  prolapse, 
and  anteflexion  of  the  gravid  womb,  resisting  other  treatment,, 
and  threatening  to  become  incarcerated,  may  call  for  the  termina- 
tion of  gestation. 

Certain  Nervous  Diseases. — In  the  course  of  acute  mania 
and  melancholia,  or  in  chorea,  and  possibly  in  general  pruritis, 
the  question  of  terminating  pregnancy  may  be  considered. 

Certain  Blood  Diseases. — If  pernicious  anemda  or  leukocy- 
themia  arises  in  pregnancy  or  is  made  much  worse  by  the  advent 
of  pregnancy,  the  question  of  terminating  the  woman's  condition 
may  be  considered. 

In  any  of  these  indications  the  question  is  an  anxious  one,, 
and  should  not  be  decided  by  the  attending  physician  on  his  own 
responsibility,  no  matter  what  his  experience  or  skill  may  be. 
There  should  invariably  be  a  consultation,  so  that  the  responsibility 
may  be  shared  and  the  operator  may  be  free  from  criticism. 

Methods  of  Inducing  Abortion. — ?»Iany  plans  have  been  advo- 
cated, but  most  of  them  have  been  found  either  too  slow,  too 
dangerous,  or  ineffectual.  Such  are  the  administration  internally 
of  ergot,  rue,  sabina,  aloes,  and  of  cotton-root;  injections  upon 
the  cervix  or  between  the  membranes;  the  insertion  of  inflated 
ruljber  bags  in  the  vagina  or  in  the  uterus;  rapid  or  gradual  dila- 
tation of  the  cervix;  perforation  of  the  membranes;  injections  of 
irritating  substances,  as  Monsell's  solution,  into  the  womb;  and 
an  electrical  current. 

The  method  emj^loyed  by  myself  with  satisfaction  in  a  num- 
ber of  cases  may  be  described  as  follows:  The  woman  is  anesthet- 
ized and  placed  in  the  dorsal  ])Osilion  upon  an  operating  table. 


INDUCTION  OF  PREMATURE   LABOR.  799 

The  vagina  and  vulva  are  disinfected.  The  anterior  Hp  of  the  cer- 
vix is  fixed  with  a  double  tenaculum,  and  the  cervical  canal  is 
dilated  cautiously  with  branched  dilators  (Baer's  and  Wathen's). 
An  Emmet's  curetment  forceps  is  inserted  into  the  womb,  opened 
and  shut  in  several  directions  so  as  to  crush  the  ovum,  and  then 
withdrawn  with  whatever  portion  of  the  ovum  or  embryo  that 
comes  with  it.  It  is  impracticable  to  remove  the  whole  ovum  at 
once.  Iodoform  gauze  is  then  packed  in  the  lower  uterine  segm.ent 
and  in  the  cervical  canal,  and  gauze  is  packed  in  the  vagina.  The 
gauze  remains  in  place  twenty-four  hours.  On  its  removal,  if 
the  remainder  of  the  ovum  is  not  yet  discharged  from  the  external 
OS,  the  cervix,  now  much  softened  and  easily  stretched,  is  further 
dilated  by  branched  dilators  or  by  the  fingers,  and  the  uterine 
cavity  is  emptied  of  all  its  contents  as  after  an  ordinary  abortion 
by  the  curet,  the  finger,  and  a  placental  forceps  (Emmet's  curet- 
ment forceps).  If,  for  any  reason,  as  in  the  exhaustion  of  hyper- 
emesis,  the  administration  of  an  anesthetic  is  undesirable,  the 
dilatation  of  the  cervix  may  be  made  almost  painless  by  the  in- 
jection into  the  cervix  at  four  different  points  of  Barker's  fluid, 
;5-eucain,  adrenalin  chlorid,  and  normal  salt  solution. 

While  the  interruption  of  pregnancy  before  the  sixth  month  is 
called  the  induction  of  abortion,  the  method  just  described  is  only 
practicable  up  to  the  fourth  month.  After  that  time  abortion  is 
induced  in  the  same  manner  as  premature  labor. 

INDUCTION  OF  PREMATURE  LABOR. 

In  addition  to  the  indications  for  the  induction  of  abortion 
there  are  special  indications  for  the  premature  interruption  of 
pregnancy  after  the  child  has  become  viable.  The  most  impor- 
tant of  these  is  a  contracted  pelvis.  The  next  in  importance, 
perhaps,  is  placenta  prasvia.  It  may  be  necessary,  in  advanced 
phthisis  or  in  grave  heart  disease,  to  secure  the  mother's  delivery 
before  term,  in  order  tnat  the  child  may  be  born  before  the  fatal 
termination  of  her  disease,  which  is  evidently  close  at  hand,  or  to 
save  her  the  strain  of  the  last  month  of  pregnancy  and  to  insure 
her  an  easy  labor.  Labor  at  term,  or  shortly  after,  may  be  induced 
in  a  woman  showing  a  dis])Osition  to  prolongation  of  pregnancy. 
Last  of  all,  in  the  rare  cases  of  habitual  death  of  the  fetus  just 
before  term,  it  is  advisable  to  induce  labor  Ijcfore  the  period  at 
which  the  child's  death  may  be  expected. 

Methods  of  Inducing  Labor. — Krausc's '  method  is  the  easiest 
for  the  general  ])raclilioncr  witliout  special  training  in  gynecological 

1"  Die  Idinstliclie  Friihgelnut,  monogiaphisch  dargeslellt,"  von  Albert  Krause, 
Breslau,  1855. 


800  OBSTETRIC   OPERATIOXS. 

manceuvers.  An  aseptic,  stiff,  silk  or  linen  bougie  (Xo.  1 7  French), 
which  has  been  soaked  for  at  least  one-half  hour  in  a  cold  corrosive 
subhmate  solution  (i:  1000),  is  anointed  with  sterile  glycerin.  The 
patient  is  placed  in  the  dorsal  position.  The  operator  passes  two 
fingers  of  his  left  hand  into  the  vagina,  inserting  one  or,  if  possible, 
both  finger-tips  into  the  cervical  canal,  which  dilate  the  cervix  and 
are  swept  around  the  lower  uterine  segment  to  sever  the  attach- 
ment of  the  membranes.  The  bougie  is  then  passed  along  the 
groove  between  the  two  fingers  until  it  enters  the  cerv-ical  canal 
and  passes  into  the  lower  uterine  segment.  It  is  pushed  further 
in  until  it  has  entirely  disappeared  within  the  uterus,  with  the  ex- 
ception of  an  inch  or  a  Httle  more  that  protrudes  from  the  external 
OS.  An  iodoform  gauze  tampon  is  packed  lightly  in  the  vagina  to 
keep  the  bougie  in  place.  x\ctive  and  effective  labor-paiiis  may 
begin  in  from  thirty  minutes  to  thirty-six  hours.  In  the  majority 
of  cases  labor  begins  within  twelve  hours.  If  it  has  not  begun  at 
the  end  of  that  time,  a  second  bougie  should  be  inserted  alongside 
the  first.  If,  after  twenty-four  hours  more,  labor  has  not  yet  begun, 
the  cervix  should  be  artificially  dilated  with  \'oorhees'  bags  or 
Bossi's  dilators,  and,  if  necessary,  the  membranes  should  be  rup- 
tured, forceps  may  be  applied  to  the  head,  or  version  may  be  per- 
formed, and  the  child  extracted  by  the  feet. 

In  about  one-fifth  of  the  cases  the  bougie  method  fails  to  excite 
labor-pains.  The  following  plan  is  the  most  certain  and  efficient: 
Dilatation  of  the  cervical  canal  to  a  diameter  of  about  7  cm.  with 
the  modified  Gau  dilator;  the  insertion  of  one  or  two  bougies  and 
also  of  a  Voorhees  bag  (medium  or  large  size). 

If  the  mother's  condition  demands  immediate  delivery,  the 
following  methods  are  available  (accouchement  force):  The  cer- 
vical canal  is  dilated  forcibly  by  the  hand  or  by  Bossi's  dilator, 
the  membranes  are  ruptured,  a  forceps  is  applied,  or  version  is 
performed  and  the  child  is  extra-cted  by  the  feet ;  vaginal  Caesarean 
section;  the  use  of  Pomeroy's  bag  for  ten  to  fifteen  minutes  and 
then  the  forcible  extraction  of  the  child  by  forceps  or  version, 

FORCEPS 

Historical. — Three  years  before  the  massacre  of  St.  Barthol- 
omew, in  1569,  William  Chamberlen,  a  Huguenot  physician, 
fled  from  France  to  England.  He  settled  in  Southampton  and 
raised  a  large  family  of  children,  two  of  whom,  both  named  Peter, 
became  prominent  physicians  in  London.  The  younger  Peter 
was  in  continual  conflict,  however,  with  his  brother  practitioners, 
and  was  se\'eral  times  summoned  for  reprimand  and  punishment 
before  the  College  of  Phvsicians.     On  one  of  these  occasions  he  was 


FORCEPS.  80 1 

accused  of  boasting  that  "he  and  his  brother  and  none  others  ex- 
celled in  these  subjects"  (difficult  labors).  This  was  in  the  begin- 
ning of  the  seventeenth  century  (1616),  and  is  the  first  record  of 
the  secret  which  remained  in  the  Chamberlen  family  for  more  than 
three  generations,  which  was  the  foundation  of  their  boast  that 
they  alone  could  be  regarded  as  skilled  obstetricians,  and  which 
enabled  them  all  to  grow  rich  by  the  practice  of  their  hidden 
method  of  dealing  with  difficult  labors.  But  instead  of  being 
honored  as  the  discoverers  of  one  of  the  most  important  inventions 
of  medicine,  posterity  has  condemned  them  for  depriving  the  world 
of  knowledge  that  might  have  saved  thousands  of  lives  and  have 
prevented  untold  suffering  during  a  hundred  years. 

The  younger  Dr.  Peter  Chamberlen  had  a  son,  also  named 
Peter,  who  was  a  remarkable  character :  a  man  of  great, 
but  ill-directed  talents  ;  possessing  some  inventive  genius  ;  an 
extensive  traveler ;  an  accomplished  linguist ;  obtaining  the 
favor  and  friendship  of  the  British  royal  family,  and  engaged 
during  the  greater  part  of  his  mature  life  in  a  lucrative  prac- 
tice among  the  upper  classes  in  London.  It  is  to  this  man, 
who  made  such  a  mark  in  his  time,  that  the  invention  of 
the  forceps  was  formerly  credited  ;  but  there  is  no  doubt,  from 
evidence  recently  come  to  light,  that  he  inherited  the  secret 
from  his  father,  who,  in  his  turn,  obtained  it  from  his  elder 
brother,  Peter  Chamberlen,  senior.^  The  idea  that  the  younger 
Peter  invented  the  instrument  was  no  doubt  fostered  by  himself, 
for  he  was  a  man  of  intense  egotism.  A  short  time  before  his 
death  he  wrote  his  own  epitaph,  which  began — 

"  To  tell  his  learning  and  his  life  to  men 
Enough  is  said  by,  '  here  lies  Chamberlen.'  " 

This  Peter  had  a  son,  Hugh,^  who  also  studied  medicine,  and 
to  whom  his  father  disclosed  the  family  secret  of  the  Chamber- 
lens.  Hugh,  who  was  extravagant,  determined  to  make  the 
most  of  his  inheritance,  and  to  part  for  a  consideration  with 
the  secret  that  had  remained  in  his  family  so  long.  He  accord- 
ingly went  to  Paris  and  offered  to  acquaint  Mauriceau  with  his 
secret  method  of  dealing  witli  difficult  head  presentations,  wliich 
up  to  that  time  had  been  managed  by  tearing  the  child  to  jjicces 
with  sharp  hooks.  For  the  disclosure  of  his  secret  Chamberlen 
asked  the  enormous  sum — in  those  days — of  ten  thousand 
dollars  (ecusj.     Mauriceau  took  the  matter  under  consideration, 

'"The  Chamberlens,"  J.  II.  Aveling,  London,  18S2. 

^The  Hugh  Chamberlen  whose  bust  may  be  seen  in  Westminster  Abbey  is  the 
son  of  this  Hugh.  He  was  a  man  of  higher  character  and  much  greater  repute  than 
his  father. 

51 


802 


OBSTE  TRIG   OPERA  TIONS. 


and,  happening  to  have  a  deformed  dwarf  in  labor,  Chamberlen 
was  asked  to  test  his  method  in  the  case.  He  did  so  and  failed 
completely,  the  patient  dying  from  a  ruptured  uterus,  unde- 
livered. This  ended  the  negotiation  for 
the  sale  of  the  secret  in  Paris.  On  his 
return  to  England  Chamberlen  translated 
and  published  Mauriceau's  book,  with  a 
preface  written  by  himself,  in  which  he 
says:  "My  Father,  Brothers,  and  my  .Self 
(tho  none  else  in  Europe  as  I  know)  have 
by  God's  Blessing  and  our  Industry, 
attained  to,  and  long  practised  a  way  to 
deliver  Wornen  in  this  case  without  any 
Prejudice  to  them  or  their  Infants."  Hugh 
Chamberlen  is  next  heard  of  in  Amster- 
dam, whither  he  had  fled  from  England 
on  accoimt  of  some  financial  difficulties. 
Here  he  had  better  fortune  than  in  Paris, 
managing  to  sell  his  secret  to  the  College 
of  Physicians  of  Amsterdam.  This  insti- 
tution immediately  induced  the  govern- 
ment to  pass  a  law  which  forbade  any  one 
to  practise  medicine  in  the  town  who  had 
not  given  satisfactory  evidence  of  possess- 
ing the  secret  now  owned  by  the  college, 
and  imparted  to  each  aspirant  for  a  medical 
degree  who  was  able  to  pay  for  it.  The 
traffic  in  the  Chamberlen  secret  continued 
until  the  middle  of  the  eighteenth  century, 
when  two  public-spirited  citizens  of  Amsterdam,  thinking  it  an 
outrage  that  a  method  for  which  such  extravagant  claims  were 
made  should  remain  a  secret,  took  a  course  in  medicine,  pur- 
chased the  knowledge  required  of  them  from  the  College  of 
Physicians,  and  published  it  to  the  world.  It  was  a  single  blade 
of  the  obstetric  forceps  !  Whether  Chamberlen  tricked  the 
college  or  the  college  cheated  its  students  is  not  known. ^ 

Before  this  time,  however,  certainly  as  early  as  1725,  the 
true  secret  had  leaked  out  in  England,  and  during  the  middle 
of  the  eighteenth  century  the  forceps  came  to  be  widely  known 
and  quite   generally  used.     There  was  for  a   long  time  m.uch 


Fig-  599- — Smellie's 
straight  forceps.  An 
eighteenth  century  Eng- 
lish forceps,  the  blades 
wrapped  with  leather, 
to  keep  them  from  slip- 
ping. 


^  Other  stories  are  that  Roonhuysen  sold  the  secret  to  Ruysch  and  a  number  of 
others;  that  a  student  of  Roonhuysen's  made  a  surreptitious  drawing  of  the  instru- 
ment and  ])ublished  it ;  that  Jacob  de  \'ischer  and  Hugo  van  der  Poll  obtained  the 
secret  from  the  daughter  of  a  former  possessor. 


FORCEPS. 


803 


speculation    as    to    the    kind    of    instrument    that    the   Cham- 
berlens  really  invented,  and  there  were  many,  some  years  ago, 


Fig.  600. — Paltjn's  forceps  or  '•hands." 


Fig.    601. — The  four  forceps  found  in  the  Chamberlen  chest. 


Fig.  602. — Chnmberlen's  vectis. 


who  doubted  that  the  invention  had  been  the  forceps  at  all.  It 
was  thought  at  one  time  to  have  been  a  forcing  powder  or  a  blunt 
hook.     It  was  l)elie\(.d  for  a  while  that  Jean  Palfyn  (1716)  had 


8o4 


OBSTETRIC   OPERATIONS. 


first  conceived  the  idea  of  an  instrument  which  was  developed 
later  by  others  into  the  forceps.  But  these  doubts  have  been  set 
at  rest.  At  Woodham,  Mortimer  Hall,  in  Essex,  owned  and 
occupied  by  Peter  Chamberlen,  junior,  was  discovered,  in  1813, 
a  chest  in  which  were  found  the  instruments  shown  in  figure 
601.  It  is  obvious  that  the  successive  possessors  of  these 
instruments  received  all  that  were  in  existence  in  order  to  pre- 
serve the  secret.  The  evolution 
of  the  forceps  at  the  hands .  of 
the  original  inventor  or  of  his 
descendants  is  plainly  seen  in  the 
illustrations.  The  Chamberlens 
were  also  the  inventors  of  the 
vectis,  or  lever,  an  instrument  no 
longer  made,  for  a  single  blade 
of  the  obstetric  forceps  answers 
the  purpose  perfectly. 

The  Chamberlen  instrument 
had  not  been  long  known  and 
employed  before  certain  defects 
in  it  were  noticed.  It  was  found 
difficult  to  introduce  it,  especially 
if  the  head  was  high  up  in  the 
parturient  tract.  It  was  also 
found  diflficult  to  lock  it,  and  the 
necessity  of  binding  the  handles 
together  was  found  to  be  incon- 
venient. 

The  first  of  these  disadvan- 
tages, the  difiiculty  of  introduc- 
tion, was  soon  discovered  to  be 
dependent  upon  the  curve  of  the 
pelvic  canal,  and  it  was  recog- 
nized that  an  instrument  to  be 
introduced  into  this  curved  canal 
should  itself  be  curved  to  corre- 
spond with  the  direction  of  the 
canal.  Almost  simultaneously,  in  England  and  France,  about 
1750,^  a  pelvic  curve  was  added  to  the  forceps — in  England  by 
Smellie,  in  France  by  Lcvret.  Each  of  these  men,  distinguished 
obstetricians  of  their  time,  added  other  important  modifications  to 
the  forceps,  which  are  worthy  of  careful  attention,  for  the  two 

'  Levret  presented  his  forceps  to  the  Academy  of  Surgery  in  1747.  Smellie 
first  published  a  description  of  his  in  1 75 1,  though  he  had  invented  the  pelvic  curve 
ten  years  before. 


Fig.  603. — A,  Levret' s  forceps 
with  a  pelvic  curve;  B,  Smellie's  for- 
ceps with  a  pelvic  curve. 


FORCEPS. 


805 


instruments  known  as  the  forceps  of  Levret  and  the  forceps  of 
Smelhe  are  the  direct  progenitors  of  the  two  types  of  forceps  in 
use  at  the  present  time.  The  Enghsh  forceps,  as  may  be  seen  in 
figure  603,  B,  is  small,  short,  and  light.  It  has,  as  may  be  seen, 
the  English  lock  ;  the  pelvic  curve  is  inadequate,  and  to  keep  the 
instrument  from  slipping  it  was  originally  wrapped  in  leather  ; 
but  the  instrument  had  good  points  about  it,  which  are  found 
modified  in  the  modern  English  forceps  of  Simpson. 

The  French  forceps  (Fig.  603,  A)  is  a  heavy,  long  instrument, 
with  powerful  handles  and  closely  approximated  blades.  The 
lock  is  the  pin  or  French  lock,  which  the  French  forceps  carry  at 
the  present  time.  In  this  instrument,  too,  the  pelvic  curve  is 
inadequate,  but  the  forceps  has  certain  advantages,  which,  modi- 
fied, may  be  found  in  many  modern  instruments.  It  was  not 
long  before  the  disadvantage  of  the  inadequate  pelvic  curve  was 


Fig.  604. — A,  French,  B,  English,  C,  German  locks. 


appreciated,  and  soon  after  the  time  of  Smellie  and  Levret  this 
feature  was  improved,  and  a  forceps  with  a  better  constructed 
pelvic  curve  came  into  use.  It  may  be  noticed  that  the  handles 
of  both  the  Levret  and  the  Smellie  forceps  are  rather  difficult  to 
grasp,  if  one  desires  to  make  a  strong  traction  upon  them.  This 
disadvantage  was  overcome  by  Busch,  a  German,  w^ho  was  the 
fir.st  to  add  the  cross-pieces  or  shoulders  to  the  handles,  which 
enable  the  operator  to  take  a  firm  and  convenient  grip  of  the  in- 
strument. 

It  is  plain  that  both  the  French  and  English  locks  each 
possess  some  advantages  and  some  disadvantages.  The  English 
lock  is  easy  of  adjustment,  but  is  not  very  secure.  The  I'^rench 
lock  is  difficult  to  adjust,  but  when  once  fastened,  is  firm  and 
unyielding.  Briinnighausen  united  the  advantages  of  both  these 
locks  and  did  away  with  their  disadvantages  in  the  lock  known 
as  that  of  Briinnighausen,  or  the  German  lock  (see  Fig.  604). 


8o6  OBSTETRIC   OPERATIONS. 

Almost  every  eminent  obstetrician  of  the  last  century  added 
some  modification  of  slight  importance  to  the  forceps  to  which 
he  attached  his  name;  so  that  the  patterns,  differing  in  a  slight 
degree  from  one  another,  have  been  almost  innumerable.  There 
are  two  types  of  modern  forceps,  however,  that  merit  descrip- 
tion— that  of  Hodge,  in  this   country,  and   that  of    Simpson,  in 


Fig.  605. — Hodge's  forceps. 


Fig.  606. — Simpson's  forceps. 


Fig.  607. — Davis'  forceps. 


Fig.  608. — Small  forceps,  modified  by  the  author  for  use  at  the  vulvar  orifice  and 

pelvic  outlet. 


Edinburgh.  They  embody  the  best  features  of  the  two  distinct 
classes  that  they  represent.  Hodge's  forceps  is  the  direct  de- 
scendant of  Levret's;  Simpson's,  of  Smellie's.  The  Hodge  for- 
ceps has  the  advantage  of  taking  an  extremely  firm  grip  upon 
the  child's  head,  and  of  allowing  great  power  in  extraction  and 
compression  of  the  head.     Its  great  disadvantage  is  that  it  may 


FORCEPS. 


807 


injure  the  child's  head  more  easily  than  almost  any  other  instru- 
ment. Simpson's  forceps — the  best  modern  instrument  for  ordi- 
nary use — has  a  cephalic  curve  so  well  constructed  that  it  can 
scarcely  injure  the  child's  head,  even  when  great  force  is  used 
in  extraction.  The  pelvic  curve  is  sufficient,  but  is  not  so  great 
as  to  embarrass  the  operator  when  the  instrument  is  applied  to 


Fig.  609. — Showing  the  direction  in  which  traction  must  be  made  by  the  handles, 
and  the  correspondence  of  the  direction  in  traction  upon  the  traction-handle  and  the 
direction  in  which  the  head  must  move. 


Hermaim's  forceps. 


the  head  low  down  in  the  pelvic  ca\'ity.  The  blades  are  of  such 
length  that  the  instrument  may  be  used  with  equal  convenience 
at  the  superior  strait  or  at  the  pelvic  outlet.  The  lock  is  the 
English  lock,  which  has  the  great  advantage  of  easy  adjustment; 
and  the  handles  arc  provided  with  shoulders  for  two  fingers,  and 
with  depressions  along  the  handle  for  the  remaining  fingers  and 


8o8 


OBSTE  TRIG   OPERA  TIONS. 


thumb  of  the  hand,  so  that  a  firm  and  convenient  grasp  can  be 
taken  of  the  instrument. 

Another  modern  instrument  deserving  description  is  the  Davis 
forceps,  carefully  constructed  upon  iron  models  of  the  fetal  head. 
If  this  instrument  is  adjusted  to  the  sides  of  the  normal  child's 
head  in  the  pelvis,  it  is  no  doubt  provided  with  a  better  cephaHc 
curve  than  any  other  forceps;  but  if  it  should  not  be  appHed  accu- 


Fig.  6li. — Tarnier's  axis-traction  forceps.      To  show  the  details,  the  hand  is  repre- 
sented in  an  improper  position  for  traction ;  below  is  one  of  the  traction  rods. 


Fig.  612. — Poulet's  forceps. 


lately  to  the  sides  of  the  head,  it  is  capable  of  doing  the  child's  head 
great  damage. 

A  useful  instrument  in  the  author's  experience  is  a  light,  short 
forceps  for  use  at  the  parturient  outlet  (Fig.  608). 

As  the  mechanism  of  labor  was  better  appreciated,  and  the 
forceps  came  into  more  general  use  in  the  latter  part  of  the  nine- 
teenth century,  it  was  realized  that  a  certain  amount  of  force 
was  lost  in  the  extraction  of  the  child's  head  by  the  necessity  of 
pulling  the  forceps  in  great  part  in  the  hne  of  their  handles.  The 
angle  at  which  this  force  met  the  direction  it  is  desired  to  impose 


FORCEPS.  809 

upon  the  head  is  shown  in  figure  609.  This  difficuky  has  been 
overcome  by  the  axis-traction  principle,  first  proposed  and  carried 
out  by  Hermann,  but  popularized  a  generation  later  by  Tarnier, 
of  Paris.  Figure  611  shows  the  best  axis-traction  forceps.^  Figure 
609  illustrates  the  coincidence  of  the  line  of  traction  with  the  direc- 
tion in  which  the  head  must  move.  ?»Iany  modifications  of  the 
axis-traction  forceps  have  been  made.  None  of  them  are  com- 
mendable that  do  not  allow  the  oblique  application  of  the  blades 
while  traction  is  made  backward  in  the  median  Une.  The  cheapest 
and  simplest  is  Poulet's,  with  strong  tapes  passed  through  eyelets 
in  the  forceps  blades,  and  fastened  to  a  handle  bent  at  right  angles. 
The  best  is  Tarnier's  latest  instrument. 

Uses  and  Functions  of  the  Forceps.— The  main  function  of 
the  forceps  is  that  of  a  tractor,  which  is  by  far  the  most  impor- 
tant. Another  function  sometimes  to  be  remembered  is  that  of  a 
rotator,  as,  for  example,  when  a  straight  forceps  is  applied  to  the 
head  in  face  presentation,  with  the  idea  of  twisting  the  chin  for- 
ward. In  a  difficult  forceps  operation  the  instrument  sometimes 
has  the  function  of  a  lever  ;  the  operator,  swaying  his  arms  a 
little  from  side  to  side,  pulls  down  first  one  side  of  the  head  and 
then  the  other,  in  this  way  dislodging  it  from  its  impacted  posi- 
tion. Last  of  all,  least  frequently  to  be  employed,  and  most  dan- 
gerous of  all  functions,  the  forceps  may  occasionally  be  regarded 
as  a  compressor ;  but  the  instrument  is  to  be  used  for  this  pur- 
pose only  in  cases  where  there  is  a  choice  between  compressing 
the  head  with  the  forceps  and  performing  craniotomy,  by  the 
former  action  extracting  a  child  that  is  almost  certainly  dead,  or 
with  a  brain  injury  that  makes  death  preferable,  but  with  one  or 
two  chances  for  life  out  of  a  hundred. 

Indications  for  the  Application  of  the  Forceps. — The  for- 
ceps is  an  instrument  designed  mainly  to  reinforce  the  vis  a  tcrgo 
in  labor.  The  most  important  indication  for  the  use  of  the  in- 
strument is  found  in  actual  and  relative  uterine  or  abdominal 
inertia.  The  expulsive  force  may  be  relatively  too  weak  if  the 
resi.stance  is  greater  than  normal ;  hence  the  forceps  is  indicated 
in  contracted  pelves,  rigidity  of  tlic  soft  parts,  and  overgrowth 
of  the  fetal  body. 

It  may  be  necessary,  in  any  case  of  head  presentation  in  labor, 
hastily  to  terminate  the  process.  This  is  especially  desirable 
if  conditions  exist  threatening  the  child's  safety,  as  premature 
detachment  of  the  placenta,  compression  or  prola]:)se  of  the  cord, 
prolonged  pressure  on  the  fetal  head,  feebleness   and  slow  action 

1  Tarnier  is  said  to  have  destroyed  ninety-nine  models  before  he  accepted  tlie 
one-hundredth  as  entirely  satisfactory  ;  for  the  description  of  his  first  models  see 
Tarnier,  "Description  de  deux  nouveaux  force]:)s,"  Paris,  1877  ;  and  "  Gaz.  des 
hop.,"  Paris,  1877. 


8lO  OBSTETRIC   OPERATIONS. 

of  the  fetal  heart,  or  sudden  danger  to  the  mother  during  the 
second  stage  of  labor,  as  in  eclampsia  or  acute  dilatation  of  the 
heart. 

There  is  a  valuable  indication  of  fetal  condition  during  labor 
in  the  action  of  the  fetal  heart.  In  case  of  serious  disturbance 
the  heart-sounds  first  increase  in  rapidity,  but  soon  become  sloAver. 
If  they  sink  to  loo  and  remain  at  that  rate  for  any  length  of  time, 
it  is  likely  that  the  child  will  be  born  dead.  It  is  a  good  practical 
rule  in  obstetrics,  therefore,  to  apply  the  forceps  and  to  deliver 
the  child  rapidly  whenever  the  fetal  heart-sounds  sink  to  loo  and 
remain  at  that  rate  for  a  minute. 

It  may  be  desirable  to  save  the  mother  the  muscular  exertion 
necessary  in  the  second  stage  of  labor,  especially  if  labor  is 
complicated  by  some  adynamic  disease,  as  phthisis,  typhoid  fever, 
or  pneumonia.  It  is  most  desirable  to  avoid  all  muscular  effort 
in  the  second  stage  of  labor  in  valvular  disease  of  the  heart. 

Finally,  labor  may  be  obstructed  by  abnormal  positions  of 
the  cephalic  extremity,  or  by  anomalies  in  the  mechanism  of 
labor,  as,  for  example,  in  face  presentations  when  the  chin  does 
not  rotate  forward,  or  in  vertex  presentations  when  the  head  is 
insufficiently  or  excessively  flexed. 

A  good  rule  of  thumb  to  govern  the  obstetrical  practitioner  is 
to  apply  the  forceps  in  head  presentations  whenever  the  presenting 
part  remains  stationary  for  two  hours  in  the  second  stage  of  labor. 

It  is  quite  as  important  to  recognize  the  contraindications  to 
the  use  of  the  forceps  as  it  is  to  understand  when  the  instrument 
is  needed.  The  contraindications  to  the  use  of  the  forceps,  ex- 
pressed dogmatically  as  rules  of  practice,  are  as  follows : 

The  forceps  must  not  be  applied  unless  the  os  is  dilated. 
There  are  exceptions  to  this  rule.  When  the  maternal  or  fetal 
life  is  threatened,  it  may  be  permissible  to  apply  forceps  through 
a  partially  dilated  os,  as,  for  example,  when  rupture  of  the 
uterus  is  threatened.  It  may  be  necessary,  in  some  cases  of 
rigid  cervix,  to  dilate  the  os  artificially  by  applying  forceps  and 
pulling  the  head  down  upon  the  cervix.  It  is  also  necessary,  in 
cases  of  valvular  disease  of  the  heart  and  in  the  adynamic  fevers, 
to  shorten  labor  as  much  as  possible  by  applying  forceps  to  the 
head  through  an  undilated  os  and  rapidly  extracting  the  child. 

The  forceps  must  not  be  applied  until  the  head  is  engaged 
in  the  superior  strait.  This  rule,  too,  admits  of  some  excep- 
tions. It  is  rarely  possible  to  fix  the  head  in  a  contracted  pelvis 
with  forceps,  when  the  powers  of  nature  are  insufficient  to  attain 
this  end.  It  is  also  justifiable  to  apply  the  forceps  to  the  head 
loose  above  the  superior  strait  in  cases  of  placenta  praevia 
with  the  head  presenting,  and  to  bring  it  down  as  a  tampon  in 
the  pelvic  canal. 


FORCEPS.  8 1  I 

The  forceps  must  not  be  applied  until  the  membranes  have 
been  ruptured.     This  rule  admits  of  no  exception. 

The  forceps  must  not  be  used  as  tractors  in  impossible  posi- 
tions and  presentations,  as,  for  example,  face  presentations  with 
the  chin  posterior. 

The  forceps  must  not  be  employed  unless  the  head  be  of 
average  size.  If  the  fetal  head  is  too  large  or  too  small,  the 
instrument  is  apt  to  slip  and  to  inflict  dangerous  injuries  upon 
the  maternal  soft  parts. 

The  forceps  must  not  be  used  when  the  disproportion  be- 
tween the  head  and  the  pelvic  canal  is  too  great. 

In  selecting  an  instrument,  the  author  would  recommend  the 
beginner,  if  he  must  restrict  himself  to  a  single  forceps,  to  pur- 
chase Simpson's.  As  soon  as  practicable,  the  Tarnier  axis-trac- 
tion forceps  should  be  added,  and  it  is  a  great  advantage  to 
possess,  in  addition  to  these  two  instruments,  a  light  short 
forceps  for  use  at  the  pelvic  outlet. 

Preparation  for  the  Operation. — The  patient's  consent,  or  the 
consent  of  her  husband  or  nearest  relative,  should  always  be 
first  secured.  An  anesthetic  renders  the  operation  less  difficult, 
and  is  to  be  recommended  to  beginners  ;  but  if  it  is  possible  to 
deliver  the  woman  in  a  short  time, — say,  half  an  hour  or  under, 
— and  if  the  difficulty  of  extraction  promises  to  be  slight,  the 
anesthetic  may  be  dispensed  with. 

The  woman  should  be  placed  in  the  dorsal  position,  if  possible, 
upon  a  table  or,  if  not,  across  the  bed,  her  legs  supported  by  assist- 
ants or  held  by  an  improvised  leg-holder  made  of  a  twisted  sheet. 
With  the  small  forceps  used  at  the  pelvic  outlet  the  lateral  position 
need  not  be  altered.  The  forceps  should  be  boiled  in  a  suitable 
instrument  tray.  Just  before  its  insertion  the  whole  blade,  both 
outer  and  inner  surfaces,  should  be  smeared  with  carbolated  vaselin 
or  sterile  glycerin. 

The  Application  of  the  Forceps. — In  using  the  Simpson  forceps, 
or  any  other  with  a  non-detachable  pin-lock,  the  left-hand  blade 
is  always  inserted  first.  The  left  blade  lies  upon  the  left-hand 
side  of  the  woman's  pelvis,  and  is  held  in  the  left  hand  of  the 
operator.  The  right-hand  blade  of  the  forceps  lies  upon  the 
right-hand  side  of  the  pelvis  when  introduced  in  position  on  the 
child's  head,  and  is  held  in  the  right  hand  of  the  operator. 
Assuming  that  the  diagnosis  of  the  presentation  and  of  the 
position  of  the  presenting  part  has  been  made,  and  that  the 
vagina  is  rendered  surgically  clean,  the  successi\-e  steps  in  the 
application  of  the  forceps-blades  may  be  summarized  as  follows  : 

Having  introduced  two   fing-ers  of  the  ricrht   hand  into  the 


8l2 


OBSTE  TRIG   OPERA  TIONS. 


Fig.  613. — Introduction  of  the  left  blade  :  first  step. 


Fig.  614. — Introducliun  of  the  left  blade  :    rotation  on  its  long  axis. 


FORCEPS. 


813 


Fig.  615. — Insertion  of  the  riglit  blade,  the  left  wrist  being  depressed  to  crowd  the 
handle  of  the  left  blade  out  of  the  way. 


Fig.  610. — Both  blades  inserted,  unrolated. 


114 


OBSTETRIC   OPERATIONS.- 


Fig.  617.— Rotation  of  a  blade  (^the  left). 


Fig.  6l8.-Boih  blade,  joined  by  the  lock  after  the  rotation  of  the  right. 


FORCEPS. 


815 


pig_  6ig.__The  grip  on  the  forceps. 


Fig.  620 


_-rhe  direction  of  the  fcrcep.-handles  at  the  inR^rior  strait  (Hodge). 


8i6 


OBSTETRIC   OPERATIONS. 


vagina,  the  left  blade,  grasped  at  the  lock  by  the  left  hand  as  a 
pen,  is  held  perpendicularly  to  the  woman's  body,  with  the  tip 
of  the  blade  opposite  the  vulva.  The  tip  of  the  blade  is  inserted 
in  the  vagina,  and  is  pressed  backward  along  the  pelvic  floor 
toward  the  sacrum.  The  blade  is  then  rotated  outward  on  its 
long  axis  to  bring  it  in  apposition  with  the  posterior  inclined  plane 
of  the  pelvis,  and  to  escape  the  promontory  of  the  sacrum  :  the 
handle  is  depressed  and  the  tip  of  the  blade  is  thus  elevated  into 
the  uterine  cavity,  the  fingers  of  the  right  hand  in  the  vagina 
guiding  the  blade  and  protecting  the  soft  parts  ;  finally,  the  handle 
is  carried  to  the  left  side  in  order  to  engage  the  tip  of  the  blade 
over  the  curve  of  the  child's  head.  '  The  right-hand  blade  is  in- 
troduced in  a  similar  manner,  substituting  the  right  for  the  left, 


Fig.  621. — The  direction  of  the  forceps-handles  with  the  head  at  the  superior  strait. 


of  course,  in  the  foregoing  description.  As  the  blades  lie  after 
their  insertion  it  is  impossible  to  lock  them,  for  both  of  them  have 
ascended  the  posterior  inclined  plane  of  the  pelvis,  after  being 
rotated  outward  on  their  long  axes.  It  is  necessary  to  bring  one 
of  them  forward  toward  the  region  of  the  acetabulum,  if  the 
head    lies   in    the  oblique  position,  before   the  blades   will    lock. 


FORCEPS. 


817 


Obviously,  the  blade  to  be  rotated  forward  within  the  pelvis 
differs  with  the  different  positions  of  the  presenting  part.  In  the 
left  occipito-anterior  position  of  a  vertex  presentation  the  right- 
hand  blade  must  be  rotated  forward,  the  left-hand  blade  lying  as 
it  was  when  first  introduced.  To  rotate  the  right  blade  the 
handle  is  lightly  supported  by  the  fingers  of  the  right  hand,  while 
the  first  two  fingers  of  the  left  hand  are  inserted  under  and  to  the 
outer  side  of  the  heel  of  the  blade  and  gently  pry  it  upward, 
outward,  and  then  inward.  If  the  operator  finds  it  more  con- 
venient, he  may  reverse  the  hands.  If  there  is  difficulty  in 
locking  the  blades,  a  depression  of  both  handles  toward  the 
perineum  often  facilitates  their  conjunction. 


-> 


Fig.  622. — The  grip  on  the  forceps  and  the  direction  of  traction. 


The  handles  being  approximated  and  the  blades  joined,  the 
operator  takes  the  grip  upon  the  instrument  shown  in  figure  622. 
The  forefinger  of  the  right  hand  is  kept  extended  against  the 
child's  scalp  to  detect  the  first  inclination  on  the  part  of  the  in- 
strument to  slip.  Too  great  compression  of  the  child's  head 
may  be  avoided  by  placing  a  folded  towel  between  the  handles, 
and  by  using  the  slack  of  this  towel  to  cover  the  shoulders  of 
the  forceps-handles,  the  operator  sa\'es  his  fingers  from  excessive 
fatigue  and  even  bruising.  The  grip  represented  in  figure  622, 
with  pressure  exerted  downward,  outward,  and  on  the  ends 
of  the  handles  upward,  enables  the  operator  to  impose  upon 
52 


8i8 


OBSTETRIC   OPERATIONS. 


Fig,  623. — The  extraction  of  the  head  from  the  vulvar  orifice:  first  stage. 


Fig.  624. — The  extraction  of  the  head  from  the  vulvar  orifice :   second  stage. 


FORCEPS. 


819 


Fig.  625. — The  extraction  of  the  head  from  the  vulvar  orifice:  third  stage. 


Fig.  626. — The  extraction  of  the  head  from  tlie  vulvar  orifice  :  fourth  stage. 


820  OBSTETRIC   OPERATIONS. 

the  head  a  movement  corresponding  with  the  axis  of  the  parturient 
canal.  If  traction  were  made  directly  outward  by  pulling  straight 
upon  the  forceps-handles,  much  of  the  force  would  be  lost  by 
dragging  the  head  against  the  symphysis  pubis. 

In  making  traction,  nature  should  be  imitated  as  closely  as 
possible,  the  intervals  between  one's  efforts  corresponding  to  the 
usual  intervals  between  the  pains,  and  the  traction  lasting  for 
about  a  minute.  In  the  intervals  of  rest  the  blades  should  be 
loosened,  or  even  unlocked,  to  spare  the  fetal  head  from  long- 
continued  and  uninterrupted  compression.  The  force  should  be 
exerted  by  the  muscles  of  the  shoulders  and  arms.  It  is  inad- 
visable to  throw  the  weight  of  the  trunk  upon  the  forceps  and 
it  is  absolutely  inexcusable  to  utilize  the  muscles  of  the  back  and 
legs,  plus  the  weight  of  the  body,  by  bracing  the  feet  while  pulling 
upon  the  forceps.  The  tractive  force  should  take  a  different 
direction  as  the  head  progresses  along  the  parturient  tract.  When 
the  forceps  is  at  rest,  the  direction  of  the  handles  is  a  good  indication 
of  the  direction  in  which  the  next  traction  should  be  made;  as  the 
head  descends  the  birth-canal  and  appears  at  the  vulvar  orifice, 
distending  the  perineum,  care  should  be  exercised  to  moderate 
the  tractive  force,  otherwise  the  head  might  be  violently  pulled 
out  through,  instead  of  over,  the  perineum.  When  the  degree  of 
distention  shown  in  figure  623  is  reached,  the  grip  of  the  forceps 
is  changed.  The  handles  are  seized  in  the  right  hand,  as  shown 
in  figure  623,  the  operator  standing  to  one  side  of  the  patient.  In- 
stead, now,  of  making  traction,  the  forceps-handles  with  each  pain 
are  lifted  and  carried  up  over  the  woman's  abdomen,  very  little 
force  being  employed.  The  outspread  fingers  and  thumb  of  the 
left  hand  push  the  head  away  from  the  perineum  and  guide  it  up- 
ward under  the  pubic  arch.  When  the  pain  passes  off,  the  forceps- 
handles  are  allowed  to  sink  again.  Finally,  just  before  the  head 
emerges,  the  grip  on  the  instrument  is  again  changed  so  that  the 
handles  may  be  almost  laid  on  the  woman's  abdomen  (Fig.  626). 
Used  in  this  way  there  is  no  better  safeguard  for  the  integrity  of 
the  pelvic  floor  than  the  obstetric  forceps. 

In  the  description  of  the  application  of  the  forceps  it  has 
been  assumed  that  the  head  is  in  a  normal  oblique  position  of  a 
vertex  presentation  and  that  the  blades  of  the  instrument  are 
applied  to  the  sides  of  the  fetal  head,  where  they  do  the  least 
damage,  and  to  the  contour  of  which  their  cephalic  curve  has 
been  adjusted.  It  often  happens,  however,  that  the  head  occu- 
pies an  abnormal  .position,  and  the  question  arises  whether  the 
forceps  shall  be  applied  at  the  sides  of  the  maternal  pelvis,  where 
the  blades  are  not  likely  to  injure  the  woman,  or  whether  an 


FORCEPS.  821 

attempt  must  be  made  to  adjust  the  blades  to  the  sides  of  the 
fetal  head  regardless  of  the  additional  risk  to  the  mother.  If, 
for  example,  the  head  is  transverse,  as  it  usually  is  when  detained 
at  the  pelvic  inlet  in  a  contracted  pelvis,  one  blade  must  lie 
behind  the  symphysis  and  the  other  in  front  of  the  promontory 
if  they  are  to  be  placed  at  the  sides  of  the  fetal  head.  It  is  pos- 
sible to  so  adjust  them,  if  one  possesses  manual  dexterity  and  is 
skilled  in  the  use  of  the  forceps,  but  there  is  always  a  danger  of 
perforating  the  posterior  uterine  wall  in  the  attempt.  It  is  better 
under  these  circumstances  to  place  the  blades  obliquely,  the 
posterior  behind  the  promontory  of  the  occiput,  the  anterior  in 
front  of  the  chin  and  mouth.  By  this  adjustment  the  fetal  head 
is  not  likely  to  be  so  badly  damaged  as  if  the  forceps  were 
applied  directly  over  the  face  and  the  occiput,  the  anterior  rota- 
tion of  the  latter  is  facilitated,  and  the  woman  is  subjected  to  no 
extra  risk. 

It  is  not  infrequently  necessary  to  apply  the  forceps  to  the 
head  in  a  normally  oblique  position,  but  with  the  occiput  directed 
posteriorly.  As  the  head  descends,  anterior  rotation  should 
occur,  and  it  is  to  be  considered  whether  the  grip  of  the  instru- 
ment will  interfere  with  the  rotary  movement  of  the  head  upon 
the  pelvic  floor.  As  a  rule,  it  does  not  if  the  precaution  is  ob- 
served to  disengage  the  blades  completely  from  each  other  by 
unlocking  them  after  each  tractive  effort.  If  spontaneous  rotation 
does  not  occur,  the  forceps  is  used  as  a  rotator  with  each  traction 
till  the  instrument  almost  turns  upside  down.  As  soon  as  rotation 
is  accomplished,  the  forceps-blades  must  be  rotated  into  their  ap- 
propriate positions  over  the  sides  of  the  head,  or,  if  it  is  difficult  to  do 
this,  they  should  be  withdrawn  and  reinserted.  To  give  a  concrete 
example  :  In  a  right  occipitoposterior  position  of  a  vertex  pres- 
entation the  two  blades  of  the  forceps  are  inserted  along  the 
posterior  walls  of  the  pelvis  to  either  side  of  the  promontory  ; 
the  right  blade  is  then  rotated  forward  until  it  lies  under  the 
right  acetabulum.  As  the  occiput  rotates  forward  after  encoun- 
tering the  resistance  of  the  pelvic  floor,  the  long  anteroposterior 
diameter  of  the  head  shifts  from  the  right  to  the  left  oblique 
diameter  of  the  maternal  pelvis,  bringing  the  forceps-blades 
directly  over  the  face  and  the  occipital  protuberance.  The  left 
blade  must,  therefore,  be  rotated  forward  and  the  right  backward, 
or,  if  it  is  difficult  to  rotate  the  blades,  they  must  be  withdrawn 
and  reinserted  as  for  a  right  occipito-anterior  position  of  a  vertex 
presentation. 

If  the  occiput  rotates  into  the  hollow  of  the  sacrum,  the  head 
should  be  extracted  from  the  vulvar  orifice  by  the  following 
manoeuver  :  The  forceps-handles  are  raised  gradually  and  inter- 
mittently  until   almost   the  largest  diameters  of  the  head  have 


822 


OBSTETRIC   OPERATIONS. 


Fig.  627. — Overdistention  of 
the  perineum  in  persistent  occipito- 
posterior  deliveries  ;  the  nose  rests 
under  the  pubic  arch.  The  handles 
at  this  point  should  be  depressed. 


escaped  ;  then,  instead  of  continuing  the  elevation,  the  left  hand 
firmly  supports  the  head  through  the  perineum  and  the  forceps- 
handles  are  depressed,  turning  the  fetal  face  out  from  behind  the 
symphysis.  In  this  way  the  perineum  and  pelvic  floor  are  some- 
what relieved  of  the  tremendous  strain  imposed  upon  them  in  a 

persistent  posterior  position  of  the 
occiput.  In  applying  the  axis- 
traction  forceps,  the  bars  are  closed 
against  the  blades,  which  are  in- 
serted in  the  ordinary  manner. 
After  adjusting  the  blades  to  the 
sides  of  the  child's  head  if  possible, 
or  in  an  oblique  diameter  of  the 
pelvis,  the  blades  are  locked;  the 
pin- lock  of  Tarnier's  instrument  is 
screwed  moderately  tight;  the  con- 
necting bar  between  the  handles  is 
thro\Mi  across,  locked,  and  screwed 
until  the  blades  take  a  firm  but  not 
too  forcible  grip  on  the  fetal  head. 
The  traction  bars  are  then  sprung 
loose  at  their  lower  end  and  the  handle  is  adjusted  to  them  and 
locked.  Traction  should  be  made  in  a  line  as  nearly  as  possible 
coinciding  with  the  axis  of  the  pelvic  inlet — namely,  backward 
and  downward.  To  do  this  even  approximately  the  woman  must 
be  placed  upon  a  bed  or  table  with  her  buttocks  projecting  well 
beyond  the  edge  and  the  axis-traction  handle  of  the  forceps  must 
be  pulled  downward  and  backward  as  far  as  possible.  To  pro- 
tect the  perineum  from  injur}' by  the  traction  rods  a  Sims  specu- 
lum should  be  held  in  place  during  the  tractive  efforts.  Between 
the  tractions  the  bar  joining  the  handles  should  be  unscrewed  and 
thrown  out  of  place  and  the  pin-lock  should  be  unscrewed,  thus 
relieving  the  fetal  head  from  continued  pressure.  As  soon  as  the 
fetal  head  has  descended  well  into  the  pelvic  cavit}'  the  axis-trac- 
tion principle  becomes  unnecessar}-.  The  handle  should,  therefore, 
be  removed,  the  bars  fastened  in  their  places  by  the  blades,  and 
the  forceps  used  as  an  ordinaiy  instrument  or  else  withdrawn  and 
replaced  by  a  Simpson  forceps.  Statistics  as  to  t\\Q  frcguoicy  of 
forceps  operations  have  neither  interest  nor  value.  They  vary 
enormously  in  different  clinics,  in  different  classes  of  society,  and 
in  the  hands  of  different  operators.  The  author  is  an  advocate  of 
the  frequent  use  of  forceps,  belie\'ing  that  more  harm  arises  from 
inordinate  delay  in  labor  to  mother  and  infant  than  can  be  traced 
to  the  use  of  the  instrument  in  careful  and  skilful  hands.  The 
mortality  of  a  forceps   operation,  per  sc,   should    be  iiiL      The 


FORCEPS. 


82- 


Fig.  628. — Axis-traction  forceps  ;   head  at  the  superior  strait. 


1.J 

Fig.  629. — Ax  is- traction  forceps  ;   head  in  the  pelvic  cavity. 


824  OBSTETRIC   OPERATIONS. 

most  frightful  damage,  however,  has  been  inflicted  upon  both 
mother  and  child  by  the  unskilful  and  careless  use  of  the  instru- 
ment. The  pelvic  joints  have  been  sprung  apart  by  too  forcible 
traction  ;  the  lower  uterine  segment  with  an  undilated  os  has  been 

caught  in  the  grip  of  the 
blades  and  has  been  cut 
through  into  the  peritoneal 
cavity;  the  posterior  wall  of 
the  lower  uterine  segment  has 
been  perforated  by  the  tip  of 
one  blade;  the  child's  scalp 
has  been  cut  and  a  forceps- 
blade  forced  between  its  scalp 
and  the  skull;  in  an  attempt 
to  apply  forceps  to  the  breech 
in  the  mistaken  notion  that 
it  was  the  head,  the  tip  of 
a  forceps-blade  has  torn  the 
_J       perineum  of  a   female   infant 


Fig.  630.-T0  bring  down  a  foot      i^to   the   rectum;   the  vaginal 

when  it  is  against  the  face,  the  knee  may  vault  haS  been  perforated  and 
be  bent  by  pressure  in  the  popliteal  space  ^J^g  vaginal  walls  deeply  CUt, 
rmodified  from  Farabeul  and  Varnier).  1    r  ^        •     1       1     •      xi 

\  and  frequently,  mdeed,  is  the 

\  pelvic  floor  torn,  often  into  the 

rectum,  by  a  failure  to  elevate  the  handles  sufficiently  and  to 

moderate  the  tractive  force  as  the  head  is  extracted  from  the  vulvar 

orifice. 

EXTRACTION  OF  THE  BREECH. 

Breech  labors  are  normally  slow  and  tedious.  The  indica- 
tions for  interference  are:  delay  for  much  more  than  twenty -four 
hours,  rapid  and  feeble  pulse,  signs  of  exhaustion,  elevation  of 
temperature  in  the  mother,  and  abnormally  slow  fetal  heart- 
sounds. 

Methods  of  Extraction  in  the  Order  of  their  Efficiency. — 
Manual  Method. — Seizing  a  foot  by  passing  a  hand  into  the  uterus, 
extracting  the  leg  up  to  the  knee,  thus  decomposing  the  breech 
presentation  and  affording  a  convenient  handle  to  the  fetus  by 
which  to  control  the  subsequent  progress  of  labor,  is  the  best  of 
all  methods  for  extracting  the  breech,  if  it  is  practicable.  Pinard's 
suggestion  to  push  one  thigh  outward  and  backward,  thus  flex- 
ing the  leg  upon  the  thigh,  occasionally  makes  it  easier  to  grasp 
the  foot. 

Another  plan  of  manual  extraction  is  to  place  the  hand  on 
the  infant's  back,  so  that  the  little  and  fore-fingers  hook  over  the 
crest  of  the  ilium,  while  the   middle   and  third  fingers  are  ex- 


EXTRACTION  OF  THE  BREECH. 


825 


Fig.  631. — Manual  extraction  of  breech. 


Fig.  632. — Forceps  on  breech. 


Fig.  633. — Fillet  on  breech. 


Fig.  634. — Fillet  carrier. 


826  OBSTETRIC   OPERATIONS. 

tended    along    the    spine.      This    is    not    so    good.      For    both 
manoeuvers  the  patient  must  be  anesthetized. 

Forceps. — If  the  breech  is  low  in  the  pelvic  canal,  and  it  is 
impossible  to  pass  the  hand  into  the  uterine  cavity  to  seize  a 
foot,  it  may  be  most  convenient  to  apply  forceps  over  the 
trochanters.  By  avoiding  compression  of  the  handles,  and 
simply    making    traction    by    hooking    one's    fingers    over    the 


Fig.  635. — The  handle  of  a  long  forceps  used  as  a  blunt  hook. 

shoulders  of  the  instrument,  the  breech  ma}'  be  extracted  readily, 
with  no  danger  to  the  child. 

Extraction  by  Fillet, — Each  end  of  a  strip  of  bandage  about  two 
inches  wide  may  be  passed  between  the  thigh  and  the  abdomen 
and  brought  down  in  front  of  the  external  genitalia.  If  drawn 
tight,  the  loop  of  the  bandage  is  in  contact  with  the  child's  sacrum. 
A  firm  and  convenient  grip  is  thus  taken  upon  the  breech.  The 
fillet  is  very  difficult  to  apply  with  the  fingers.  A  fillet-carrier, 
shown  in  figure  634,  makes  the  application  easier.     A  still  better 


VERSION.  827 

appliance  is  a  fillet-carrier  constructed  like  a  Bellocq's  canula.  An 
anesthetic  is  required.  This  plan  is  excellent  if  the  manual  extrac- 
tion is  impossible,  or  if  it  is  considered  inadvisable  to  use  forceps. 
Blunt  Hook. — This  instrument  is  passed  between  the  thigh  and 
the  abdomen.  It  is  extremely  dangerous  for  the  infant.  It  is  verv 
likely,  indeed,  to  fracture  the  thigh  or  to  perforate  the  groin.  It  is, 
therefore,  not  recommended,  and  is  never  employed  by  the  author 
unless  the  child  is  dead. 

VERSION. 

Version  maybe  defined  as  an  operation  or  manoeuverto  change 
the  fKDsition  of  the  fetus  in  iitero.  The  object  of  version  is  usually 
to  change  a  transverse  into  a  longitudinal  presentation,  or  to 
change  the  presentation  of  one  pole  of  the  fetal  ellipse  into  a 
presentation  of  the  opposite  pole. 

The  changes  in  the  position  of  the  fetus  are  effected  by  four 
methods — postural  treatment  of  the  mother,  external  manipu- 
lation alone,  internal  manipulation  alone,  and  a  combination 
of  internal  and  external  manipulations.  As  the  child  is  brought 
to  present  by  the  cephalic  or  pelvic  presentation,  the  operation 
is  called  version  by  the  head  or  version  by  the  breech.  If  the 
foot  is  seized  and  is  extracted  in  the  operation  of  version,  the 
operation  is  called  podalic  version. 

The  operation  of  version  is  an  old  one.  Hippocrates  speaks 
of  the  difficulties  encountered  when  a  child  lies  crosswise  in  the 
uterus.  He  compares  it  to  an  olive  lying  crosswise  in  a  bottle 
with  a  narrow  neck.  But  Hippocrates  believed  that  the  infant 
could  only  be  delivered  if  it  presented  head  first,  and  therefore, 
in  cross-positions  of  the  fetus,  if  the  effort  to  turn  it  with  the 
head  toward  the  maternal  pelvis  did  not  succeed,  embryotomy 
was  to  be  performed  by  tearing  the  child  to  pieces  with  sharp  hooks. 

In  some  aboriginal  tribes  a  woman  is  seized  by  the  feet,  sus- 
pended head  downward,  and  vigorously  shaken  if  labor  is  delayed. 

In  Japan,  before  the  country  reached  its  present  high  stage 
of  civihzation,  it  was  customary  to  apply  massage  to  the  abdomen 
of  pregnant  women  in  order  to  straighten  out  a  possibly  faulty 
position  of  the  fetal  ellipse.  In  many  primitive  races  some  form 
of  version  has  been  and  is  in  vogue,  handed  down  as  a  custom  of 
ancient  origin. 

Indications  for  Version. — The  most  important  and  the 
most  frequent  indication  for  version  is  found  in  a  transverse  posi- 
tion of  the  fetus  in  iitcro.  In  order  to  secure  delivery,  one  or 
the  other  of  the  poles  of  the  fetal  ellipse  must  be  substituted  for 
the  shoulder,  which  usually  presents  in  a  transverse  position 
of  the  fetus. 


S28  OBSTETRIC   OPERATIONS. 

Contracted  pelves  are  an  indication  for  the  performance  of 
version,  when  it  is  thouglit  tliat  the  child's  head  can  be  brought 
through  the  contracted  pelvic  canal  more  easily  with  the  small  end 
of  the  wedge  coming  first  than  last.  If  it  is  necessary  to  deliver 
the  mother  rapidly,  in  cases  of  sudden  danger,  when  the  head  is 
presenting  but  not  engaged,  as  in  eclampsia,  premature  detach- 
ment of  the  placenta,  rupture  of  the  uterus,  embolism,  and  death 
of  the  mother,  podalic  version  furnishes  the  most  rapid  means 
of  delivery.  In  malpositions  of  the  head,  as  presentation  of  the 
ear,  of  one  parietal  bone,  of  a  brow  or  face,  it  may  be  better  to 
substitute  for  the  unfavorable  presentation  of  the  head  the  more 
favorable  presentation  of  the  breech,  which  is  secured  by  podalic 
version,  or  by  version  by  the  breech.  In  placenta  praevia,  if  the 
head  is  presenting,  version  is  indicated,  in  order  to  bring  down 
the  breech  as  an  intrapelvic  tampon  upon  the  bleeding  placental 
site.  In  prolapse  of  the  umbilical  cord,  version  is  indicated  if  the 
cord  can  not  be  returned  into  the  uterine  cavity  and  kept  there. 

Before  undertaking  the  operation  of  version,  it  is  quite  as 
important  to  reahze  the  contraindications  to  the  operation  as 
it  is  to  recognize  the  indications.  Version  is  positively  contra- 
indicated  if  the  presenting  part  is  firmly  engaged  in  the  pelvic 
canal  and  has  passed  out  of  the  external  os  ;  also,  if  the  con- 
traction-ring is  so  high  that  a  rupture  of  the  lower  uterine  seg- 
ment is  threatened  if  version  is  attempted. 

While  these  are  the  only  positive  contraindications  to  the 
operation,  the  following  conditions  may  make  it  difficult,  dan- 
gerous, or  quite  impossible  : 

An  undilated  and  undilatable  vagina  ;  a  similar  condition  of 
the  cervix.  These  obstructions  may  usually  be  overcome  under 
anesthesia,  but  they  may  be  insuperable  obstacles  to  the  per- 
formance of  version. 

It  may  be  impossible  to  effect  an  entrance  into  the  uterus,  as 
when  the  liquor  amnii  has  long  been  drained  away  and  the 
uterus  is  firmly  contracted,  if  the  uterus  is  permanently  con- 
tracted in  what  is  called  a  tetanic  spasm,  if  there  is  some  obstruc- 
tion on  the  part  of  the  fetus,  as  hydrocephalus  and  spina  bifida 
with  a  large  meningocele,  or  if  the  presenting  part  is  pressed 
firmly  upon  the  superior  strait.  The  last-named  difficulties  may 
be  obviated  by  placing  the  woman  in  the  knee-chest  posture. 

Prolapse  of  the  arm,  at  one  time  considered  a  serious  ob- 
stacle to  the  performance  of  version,  is  no  longer  so.  The  phy- 
sician's hand  can  readily  pass  by  the  arm,  and  indeed  it  is  some- 
times an  advantage  to  pull  the  arm  out  of  the  external  os  before 
attempting  version. 

It  may  be  impossible  to  bring  the  feet  down  in  podalic  version 
after  they  are  grasped.      This   difficult)'  may    be   overcome   by 


VERSIOX. 


829 


applying  a  fillet  to  the  foot,  and,  while  traction  is  made  ujjon  it, 
the  other  hand  of  the  physician  in  the  vagina  pushes  the  shoulder 
upward  and  in  the  direction  of  the  child's  head. 

In  a  case  of  the  author's  the  shoulder  and  head  were  locked 
in  the  cornua  of  a  uterus  condiformis,  making  version  impossible. 

Certain  conditions  may  interfere,  also,  with  the  manipulation 
of  the  external  hand  in  combined  and  in  podahc  version,  as  an 
excessive  amount  of  fat  in  the  abdominal  wall,  or  convulsions  in 
eclampsia,  epilepsy,  chorea,  and  hysteria.  On  the  other  hand, 
the  conditions  most  favorable  for  the  operation  are:  a  uterus  dis- 
tended by  liquor  amnii,  a  dilated  os,  a  uterine  muscle  that  is  not 
irritable,  abdominal  muscles  that  are  flexible  and  thin,  and  a 
cervix  well  dilated  or  easilv  dilatable. 


Fig.  636. — Diagram  of  knee-elbow  po-tuie  fur  internal  version.      The  lower  part  of 
the  hollow  of  the  uterus  is  lifted  out  of  the  pelvis  (Dickinson). 


Postural  Version. — In  this  method  the  woman  is  put  in  dif- 
ferent positions  to  influence  the  position  of  the  child  by  the  force 
of  gravity.  For  example,  if  the  brow  presents,  the  woman  is 
turned  on  that  side  toward  which  the  fetal  back  looks,  so  that  the 
breech  may  drop  to  that  side,  and  thus  bring  the  vertex  to  the  center 
of  the  superior  strait;  or,  if  the  head  should  be  tightly  fixed  in  the 
superior  strait,  the  woman  may  be  turned  on  that  side  toward  which 
the  face  looks,  in  order  to  promote  the  flexion  of  the  child's  hea^l, 
and  thus  favor  a  conversion  of  the  brow  presentation  into  one  of  the 
vertex. 

This  is  a  simple,  safe,  and  easy  means  of  performing  version, 
if  practicable,  but  it  usually  fails. 

Version    by    external    manipulation    mav    be    used    before 


8-.0 


OBSTETRIC   OPERATIONS. 


labor  to  convert  a  breech  presentation  into  a  presentation  of  the 
head,  or  to  correct  a  transverse  presentation.  When  the  child 
has  been  brought  into  the  position  desired,  by  a  series  of 
stroking  movements,  pads  and  a  binder  should  be  applied  to 
prevent  the  return  of  the  child  to  its  original  position.  This 
method,  while  successful  in  a  fair  proportion  of  cases,  requires 
often  an  expert's  skill ;  a  diagnosis  of  the  position  before  labor 
has  begun  ;  the  preservation  of  the  membranes  ;  thin,  flexible 
uterine  and  abdominal  walls,  and  non-irritable  muscles. 

Combined  version  was  first  proposed  by  Busch,  D'Outre- 
pont,  and  by  Dr.  Wright,  of  Cincinnati,  and  was  later  advocated 
by  Braxton  Hicks,  of  London.  The  operation  is  performed  as 
follows:  The  patient  is  placed  in  the  dorsal  position  and  is 
anesthetized.  Externally,  the  hand  nearest  the  fetal  part  to  be 
acted  upon  by  external  manipulation  seizes  this  part  through 
the  abdominal  walls,  the  operator  being  seated  facing  the  vulva. 
The  internal  hand  pushes  the  presenting  part  up  and  to  that 
side  opposite  the  fetal  part  acted  upon  by  the  external  hand. 
For  example,  in  a  shoulder  presentation,  with  the  face  of  the 
child  turned  forward  and  the  head  in  the  right  iliac  fossa, 
the  physician   seizes   the   head  with  his   left   hand,  inserts   the 

right  hand  in  the  vagina,  and 
with  two  fingers  of  this  hand 
passed  into  the  uterine  cavity 
pushes  the  child's  right  shoul- 
der upward  and  toward  the 
mother's  left-hand  side,  while 
the  head  by  external  manipu- 
lation is  pulled  downward  and 
toward  the  median  line.  In  all 
shoulder  presentations,  version 
by  the  head  should  be  pre- 
ferred to  version  by  the  breech 
in  the  combined  method,  for 
this  presentation  is  more  favor- 
able to  the  child,  and  the  head 
is  more  readily  brought  to 
present  at  the  superior  strait, 
making  the  version  easier  and 
quicker  than  if  the  breech  were 
brought  down. 
Podalic  version  was  known  in  the  time  of  the  Roman  Em- 
pire, but  was  forgotten  in  the  middle  ages  until  Ambrose  Pare 
and  his  students  revived  it  in  the  sixteenth  century.  The  opera- 
tion is  performed  as  follows:  Relaxation  of  the  uterus  and  of 
the  abdominal  muscles  is  secured  b\'  an  anesthetic.      The  lowest 


Fig.  637. — Version  in  dorsoposterior  posi- 
tion (Farabeuf  and  Varnier). 


VERSION. 


831 


Fig.  63S. — D'Outrepont's  method  of  combined  version,  modified  by  Scanzoni. 


Fig.  639. — Combined  version  by  the  breech. 


Fig.  640. — Combined  version,  Wright's  method. 


8,32 


OBS  TE  TRIG   OPERA  TIONS. 


Fig.  641. — Seizing  the  anterior  foot  in  podalic  version  (Nagel). 


Fig.  642. — Version  in  dorso-anterior  position,  first  stage  of  traction  on  lower  limb 
(Farabeuf  and  Varnier). 


VERSION. 


833 


possible  position  of  the  fetal  feet  is  secured  by  turning  the 
mother  on  that  side  toward  which  the  feet  point.  The  hand 
which,  midway  between  pronation  and  supination,  as  the  operator 
faces  the  woman's  vulva,  corresponds  with  its  palmar  surface  to 
the  abdomen  of  the  child  is  inserted  into  the  uterine  cavity,  until 
it  meets  the  anterior  foot.  This  foot  is  grasped  by  the  first  two 
fingers  and  the  thumb,  and  is  then  extracted  until  the  knee  appears 
at  the  vulva. 


Fig.  643. — The  upper  buttock  is 
moving  downward  and  the  lower  shoul- 
der rising  (Dickinson). 


Fig.  644. — Assisting  podalic  version  by 
external  manipulation  (Dickinson). 


The  advantages  of  resting  content  with  tlie  anterior  foot,  and 
of  drawing  upon  it  alone  without  seeking  for  the  other,  are  these: 
A  further  entrance  into  the  uterus  is  unnecessary.  It  is  easier 
to  hold  one  foot  than  two.  The  other  leg  is  folded  uj)on  the 
abdomen,  and  thus  secures  a  more  thorough  dilatation  of  the 
cervical  canal.  Finally,  by  pulling  upon  the  anterior  foot  one 
53 


834 


OBSTETRIC    OPERATIONS. 


is  more  likely  to  secure  a  sacro-anterior  position  of  the  breech. 
While  making  traction  upon  the  foot,  the  version  of  the  child  is 
facilitated  by  external  manipulation  of  the  head  (Fig.  644).     It  is 


Fig.  645. — Seizing  the  leg  instead  of  the  foot. 


Fig.  646. — Seizing  a  knee  instead  of  the  foot. 

occasionally  easier  to  seize  a  leg  or  the  knee  than  the  foot  (Figs. 
645,  646).  In  such  a  case  time  need  not  be  wasted  seeking  for 
the  foot.     Combined  version  by  the  breech  may  precede  or  re- 


VERSION. 


835 


place  podalic  version  with  great  advantage,  as  first  pointed  out  by 
Braxton  Hicks,  obviating  the  necessity  of  introducing  the  hand 
into  the  uterine  cavity  and  enabHng  the  operator  easily  to  seize  the 
knee  or  foot  after  it  is  brought  near  or  into  the  superior  strait. 

As  soon  as  the  knee  is  born,  the  operation  of  podahc  version 
is  finished,  and,  unless   there  is   some  indication  for  immediate 


Fig.  647. — Extiacling  an  arm  (Nagel 


delivery,  the  anesthetic  should  be  removed,  the  patient  should 
be  turned  upon  her  back,  and  should  be  allowed  to  expel  the 
child  spontaneously  until  the  umbilicus  appears  in  view.  The 
delay  secures  a  more  thorough  dilatation  of  the  cervical  canal, 
and  produces  a  paretic  condition  of  the  circular  muscle  of  the 
cervix.  The  advantages  of  this  condition  of  the  cervix  are 
obvious  when  it  comes  to  the  extraction  of  the  after-coming 
head.  With  an  undilated  cervical  canal  and  a  rigid  cervical 
muscle,  the  neck  is  likely  to  be  grasped  in  so  firm  a  hold  that 


8-^6 


OBSTE  TRIG   OPERA  TIONS. 


all  efforts  to  extract  the  head  are  unavailing  until  the  child  is 
asphyxiated.  In  rare  cases  rapid  extraction  may  be  indi- 
cated. If  it  is,  the  legs  and  trunk  are  pulled  upon  forcibly,  as 
shown  in  figures  648  and  649.  The  child's  body  being  slippery, 
should  usuaUy  be  enveloped  in  a  towel.  When  the  child  is 
bom  to  the  umbilicus  the  pressure  upon  the  cord  is  great, 
and  delay  in  its  extraction  means  an  asphyxia  so  deep  that  it 
is  unlikely  the  child  can  be  revived.  From  this  moment,  there- 
fore, the  attendant  must  put  forth  every  effort  possible  to  secure 
the  most  rapid  delivery  of  the  infant,  which  is  effected  by  the 
following  methods :  The  arms,  if  extended  alongside  of  the 
child's  head,  as  they  usually  are  after  version,  must  be  extracted 
in  the  following  manner :  locate  the  posterior  arm  by  the 
position  of  the  trunk  and  shoulders.  To  deliver  the  right  arm, 
grasp  the  legs  with  the  left  hand,  the  middle  finger  above  the 
internal   malleoli,  the  index  and  middle   fingers   above  the  ex- 


Fig.  648. 


-Method  of  seizing  the 
breech. 


Fig,-  649. 


-Method  of  seizing  both 
feet. 


ternal  malleoli.  Raise  the  child's  body  upward  and  outward 
over  the  mother's  right  thigh.  This  movement  should  be  suffi- 
ciently forcible  to  bring  the  right  shoulder  well  down  in  the 
pelvis.  The  first  two  fingers  of  the  right  hand,  entering  the 
vagina  in  contact  with  the  right  scapula,  are  passed  along  the 
posterior  surface  of  the  arm  beyond  the  elbow,  when  the  arm 
and  forearm  are  pushed  in  front  of  the  child's  face  as  though  the 


VERSIOX. 


837 


elbow  joint  did  not  exist.  The  fingers  are  now  hooked  in  the 
elbow- joint  and  pulled  directly  downward  until  the  elbow  appears 
at  the  vulva,  the  forearm  being  flexed  by  this  movement  upon  the 
arm.  The  forearm  is  then  easily  delivered  by  extension.  The 
left  arm  is  brought  down  and  delivered  in  the  same  manner,  sub- 
stituting, of  course,  right  for  left.  The  right  hand  grasps  the 
child's  feet  and  lifts  them  over  the  mother's  left  thigh,  at  the  same 
time  rotating  them  on  their  long  axes  so  as  to  twist  tlie  body  and 
thus  bring  the  anterior  arm  into  the  posterior  portion  of  the  pelvis. 
The  fingers  of  the  left  hand  are  inserted  into  the  vagina  past  the 
elbow-joint.  The  arm  is  swept  forward  over  the  face,  as  though 
it  were  a  single  piece  without  the  elbow-joint.  The  elbow  is 
then   flexed,  pulled   downward,  and  the  forearm  extended  at  the 


Fig.  650. — Delivery  of  the  after-coming  head  by  flexion  through  seizure  of  lower  jaw, 
and  extrusion  by  means  of  pressure  in  axis  of  brim  (Dickinson). 


vulvar  orifice.  Should  the  shoulders  occupy  a  transverse  posi- 
tion, either  arm  may  be  brought  down  and  delivered  first.  After 
delivering  the  arms,  the  head  may  be  extracted  by  one  of  the 
following  methods,  given  in  the  order  of  their  efficiency  and 
safety : 


838 


OBSTETRIC   OPERATIONS. 


Wigand's  Method. — In  this  method  the  first  three  fingers  of 
the  supinated  hand  are  inserted  into  the  vagina,  that  hand  being 
employed  whose  palm  corresponds  to  the  abdomen  of  the  child. 
Over  the  forearm  of  this  hand  the  child's  body  rests  astride. 


Fig.   651. — First  step  of  Mauriceau's  method,  an  assistant  making  suprapubic  pres- 
sure on  the  head. 


The  index-finger  of  the  hand  in  the  vagina  is  inserted  in  the 
child's  mouth,  care  being  exercised  to  avoid  the  eye-sockets. 
Sufficient  traction  is  exerted  upon   the  lower  jaw  to  secure  and 


VERSION. 


839 


maintain  flexion  of  the  head.  The  disengaged  hand  now  locates 
the  head  through  the  abdominal  wall  above  the  pubes,  and 
delivery  is  accomplished  by  suprapubic  pressure  in  the  axis  of 
the  parturient  canal,  and  by  the  elevation  of  the  child's  body 
toward  the  mother's  abdomen. 

Mauriceau's  Method. — One  hand  is  inserted  in  the  vagina,  as 
described  above,  and  one  finger  is  placed  in  the  child's  mouth. 
The  other  hand  is  passed  along  the  child's  back  until  the  middle 
finger  rests   upon   the   occipital  protuberance.      The  index-  and 


P'ig.  652. —  Second  step  of  Mauriceau's  metliod. 


ring-fingers  are  flexed  over  the  clavicles,  and  traction  is  made  by 
both  hands  at  once,  the  force  upon  the  jaw  and  the  pressure 
upon  the  occipital  protuberance  keeping  the  head  well  flexed, 
while  the  traction  upon   the   shoulders  extracts  the   head  in  the 


840 


OBSTETRIC   OPERATIONS. 


direction  of  the  parturient  canal.  As  the  head  descends  upon 
the  pelvic  floor,  the  child's  body  is  carried  upward  toward  the 
mother's  abdomen.  Properly  directed  suprapubic  pressure  by 
an  assistant  increases  the  efficiency  of  this  method,  and  makes  it, 
indeed,  the  most  effective  of  all  methods  in  extracting  the  after- 
coming  head.  Combined  with  the  Walcher  posture  in  the  mother 
it  should  be  the  method  of  election  in  cases  of  contracted  pelvis. 
Prague  Method. — The  child's  ankles  are  grasped  with  the 
right  hand  pronated,  the  middle  finger  being  placed  between  the 
legs  just  above  the  internal  malleoli,  the  index-  and  ring-fingers 
above  the  external  malleoli.  The  index-finger  of  the  left  hand 
is  flexed  over  one  clavicle,  and  the  remaining  fingers  of  the  same 
hand  over  the  other  clavicle.  Traction  directly  downward  is 
now  made  with  both  hands  until  thie  perineum  is  well  distended. 


F'g-  653. — The  method  of 
extracting  the  trunk. 


Fig.  654. — The  Prague  method  of  extracting 
head. 


The  right  hand  then  loosens  its  hold  upon  the  ankles,  and  again 
grasps  them  as  described  above,  but  approaching  them  at  their 
anterior  surface.  The  child's  feet  are  now  in  contact  with  the 
back  of  the  right  hand.  The  feet  are  then  raised  by  a  circular 
movement  toward  the  mother's  abdomen,  while  the  left  hand  as 
originally  placed  is  used  as  a  fulcrum,  around  which  the  head 
moves  until  it  is  finally  forced  out  of  the  parturient  outlet  by  a 
Icver-Iike  movement  on  the  part  of  the  child's  body. 


VERSION. 


841 


Forceps. — An  assistant  should  raise  the  child's  body,  sup- 
porting its  arms  and  legs,  and  thus  keeping  them  out  of  the  way 
of  the  operator,  who  rapidly  applies  the  blades  to  the  sides  of  the 
child's  head.  Traction  is  made  in  the  direction  of  the  axis  of 
the  parturient  canal,  and  the  head  is  finally  delivered  by  lifting 
the  handles  of  the  forceps,  the  disengaged  hand  protecting  the 
perineum  as  much  as  possible. 

Deventer's  Method. — The  child's  body  is  seized  as  in  the 
Prague  method,  but  the  arms  are  still  alongside  the  child's  head 


Fig.  655.  —  Deventer's  method  of  extraction  of  the  after-coming  head  and  arms 

(Dickinson). 


and  need  not  be  extracted  first.  The  body  is  pulled  directly 
downward  toward  the  ground,  until  the  shoulders  descend  and 
press  upon  the  pelvic  floor.  The  child's  body  is  then  carried 
downward  and  backward  under  the  woman's  buttocks,  the    head 


842  OBSTETRIC   OPERATIONS. 

being  rolled  out  of  the  parturient  outlet  between  the  arms, 
which  easily  follow  after.  To  do  this  the  woman's  buttocks  must 
project  well  beyond  the  edge  of  the  bed,  and  the  child  must  be 
carried  well  under  them.  The  operation  is  only  possible  under 
the  most  favorable  conditions,  and  is  not  always  to  be  relied  upon. 
It  has,  however,  the  merits  of  simplicity  and  rapidity. 


EMBRYOTOMY. 

Embryotomy  is  a  mutilating  operation  upon  the  fetus.  The 
term  is  generic, and  includes  the  following  operations:  Craniotomy, 
decapitation,  evisceration,  and  amputation  of  the  extremities. 

Craniotomy In  this  operation  the  child's  head  is  perforated, 

the  contents  evacuated,  and  the  head  thus  diminished  in  size. 
The  forcible  extraction  of  the  evacuated  head  is  often  also  a  part 
of  the  operation.  The  operation  may  be  indicated  upon  a  dead 
or  upon  a  living  child.  In  the  former  case  the  indications  for 
the  operation  may  be  comparatively  trivial.  If  the  mother  can 
be  saved  any  additional  risk  or  suffering  by  the  rapid  delivery  of 
the  mutilated  child,  craniotomy  is  not  only  justifiable,  but  advis- 
able. In  case  of  prolapse  of  the  umbilical  cord,  with  a  con- 
tracted pelvis,  the  commonest  condition  that  calls  for  craniotomy 
upon  a  dead  infant,  it  is  far  better  to  open  the  head  and  to  deliver 
the  child  easily  with  a  cranioclast,  than  to  apply  the  forceps  to  the 
head  at  the  superior  strait  and  to  subject  the  mother  to  the 
delay,  pain,  and  danger  of  a  prolonged  forceps  operation,  when 
nothing  is  to  be  gained  by  it. 

Craniotomy  upon  the  living  child  is  only  justifiable  in  excep- 
tional circumstances.  To  condemn  this  operation,  however, 
unreservedly  and  without  exception  is  a  mistake.  In  cases  of 
difficult  labor,  if  the  pelvis  is  contracted  or  the  child  over- 
grown, and  the  physician  must  make  a  choice  between  Cesa- 
rean section,  pubiotomy,  or  craniotomy,  if  he  has  no  skill  in  sur- 
gical work  and  is  unable  to  procure  expert  assistance,  it  is  better, 
unquestionably,  to  sacrifice  the  child  for- the  mother's  sake,  rather 
than  to  attempt  a  serious  surgical  operation,  amid  unfavorable 
surroundings,  and  performed  by  an  unskilful  operator  whose 
mortality  must  be  very  great. 

Every  attempt  must  be  made  to  avoid  the  destruction  of  a 
living  child,  of  course;  and  if  the  operator  feels  himself  possessed 
of  sufficient  skill  to  attempt  the  more  serious  operations  of  Cesarean 
section  or  ])ubiotomy  with  fair  prospect  of  success,  or  if  he  can  sum- 
mon to  his  aid  an  expert  surgeon,  he  should  not  think  of  performing 
craniotomy  upon  the  living  child.     But  under  certain  circumstances 


EMBRYOTOMY. 


843 


craniotomy  upon  a  living  infant  is  a  justifiable  operation,  and 
one  not  to  be  unreservedly  condemned. 

The  Instruments  for  the  Operation. — Embryotomy  is  the 
oldest  operation  of  obstetrics  and  the  instruments  for  perform- 
ing it  make  an  interesting  historical  collection.  The  sharp 
hook  or  crotchet  in  its  numerous  forms  had  a  place  in  the  obstet- 
rician's armamentarium  for  many  centuries.  At  the  present  day 
the  operator  may  need  for  craniotomy  a  perforator,  a  head  seizer 


Fig.  656. — A,   Sharp  hook  or  crolcliet  ;    B,   Baudelocque's  cephalotribe. 


or  cranioclast,  and  a  head  crusher  in  its  various  forms  of  ccphalo- 
tribe,  basiotribc,  or  basilyst. 

Perforators. — The  best  perforator  is  Blot's.  .Suicllic's  perfora- 
tor or  Hodge's  scissors  answer  the  purpose  well  enough,  and  in 
the  absence  of  an  instrument  specially  devised  for  the  purpose, 
any  long,  sharp-pointed  scissors  serves  admirably. 


844 


OBSTETRIC   OPERATIONS. 


Fig.  657. — Smellie's  perforator. 


Fig.  658. — Blot' s  perforator. 


Fig.  659. — Oldest  form  of  cranioclast. 


Fig.  660. — Simpson's  cranioclast. 


Fig.  661. — Braun's  cranioclast. 


Fig.  662. — Cranioclast  modified   by  the  author  with  a  pelvic  curve  which  Braun's 

does  not  possess. 


EMBRYOTOiMY. 


845 


Fig.  663.— Hicks' cephalotribe. 


Fig.  664. — Tarnier's  basiotribe 


tr 


Fig.  665. — Tarnier's  basiotribe 
(separate  parts). 


Fig.  666.— The  second  blade  of  the 
basiotribe  has  crushed  the  sinciput. 


846 


OBSTETRIC   OPERATIONS. 


Head  Seizers  or  Cranioclasts. — This  instrument  was  invented 
by  Sir  James  Y.  Simpson.  It  has  been  much  improved  by  Carl 
Braun  and  the  author  has  added  to  the  latter  instrument  a  pelvic 
curve,  which  facilitates  its  application  at  the  superior  strait.  The 
cranioclast  is  made  with  two  blades  :  one  for  insertion  inside,  the 
other  outside,  the  skull.  The  handles  are  provided  with  a  screw 
and  nut  to  bring  them  close  together,  so  as  to  give  the  blades  a 
powerful  grip  upon  the  skull. 

Head  Crushers  or  Cephalotribes. — The  cephalotribe  is  the  in- 
vention of  the  younger  Baudelocque.  It  is  simply  a  heavy, 
powerful  forceps  with  the  handles  screwed  together  so  as  forci- 
bly to  compress  the  skull  between  the  blades.  The  best  cephalo- 
tribe is  Tarnier's  basiotj'ibc,  which  combines  a  perforator  and  a 
powerful  head  crusher. 

Other  modern  instruments  for  the  extraction  of  the  mutilated 


Fig.  667. — Perforation  of  the  head  begun  :  the  right  hand  is  grasping  the  handles 
of  the  instrument.  The  tips  should  not  be  separated  until  they  have  entered  the 
fontanel  (Dickinson). 


head  are  Simpson's  basilyst  and  Van  Huevel's  laminator.  The 
latter  is  designed  to  saw  off  the  face  and  the  occipital  protuber- 
ance. A  wire  ecraseur  answers  the  purpose  perfect!}'  well,  as 
was  shown  by  Barnes.  In  addition  to  these  instruments,  the 
operator  needs  a  heavy  volsella  forceps  and  a  large  metal  catheter 
to  break  up  the  brain  and  to  wash  it  out  of  the  skull. 

The  technic  of  the  operation  is  as  follows  :  The  woman 
should  be  anesthetized  not  so  much  because  the  operation  is 
painful  or  prolonged,  but  to  spare  her  the  sight  of  her  mutilated 


EMBRYOTOMY. 


847 


infant.  The  patient  is  placed  in  the  hthotomy  position,  and 
brought  well  to  the  edge  of  the  bed  or  table  on  which  she  lies. 
The  child's  scalp  is  seized  by  a  strong  volsella  forceps,  which  is 
handed  to  an  assistant,  who  pulls  upon  the  instrument  firmly, 
so  as  to  fix  the  head  at  the  superior  strait.  The  operator  then  in- 
serts two  fingers  of  his  left  hand  and  feels  for  a  suture  or  a  fontanel. 
The  perforator  is  inserted  into  the  vagina,  along  the  palmar  surface 
of  the  fingers,  and  is  plunged  into  the  skull  at  a  point  upon  which 


Fig.  668. — The  head  after  dehvery  by  the  cranioclast. 


the  finger-ti])S  rest — that  is,  through  a  fontanel  or  a  suture.  When 
it  has  entered  the  skull  the  perforator  is  twisted  about  in  all  direc- 
tions, in  order  to  break  up  the  brain,  and  is  also  opened  in  se^■eral 
different  directions  to  enlarge  the  opening  in  the  skull.  The 
large  catheter  is  next  inserted  and  attached  to  a  syringe.  A  column 
of  water  is  injected  into  the  cranial  cavity  to  wash  out  the  remaining 
brain-substance.  Next,  if  it  is  necessary,  the  size  of  the  emptied 
head  may  be  reduced  with  a  cephalotribc.  This  is  only  called  for 
in  case  of  extreme  j^elvic  contraction,  or  in  the  presence  of  some 


848 


OBSTETRIC   OPERATIONS. 


pelvic  tumor  seriously  diminishing  the  capacity  of  the  pelvic  canal. 
In  the  majority  of  cases  a  cranioclast  may  be  used  instead  of 
the  cephalotribe.  The  internal  branch  of  this  instrument  is 
inserted  within  the  skull.  The  outer  branch  is  next  introduced  in 
the  same  manner  that  one  would  insert  a  blade  of  the  forceps. 
The  two  branches  are  then  locked,  and  the  handles  are  screwed 
firmly  together,  care  being  taken  that  the  internal  branch  isinserted 
deeply  within  the  cranial  cavity,  so  that  it  shall  get  a  firm  grasp 
upon  the  skull.  The  child  is  now  extracted  in  the  same  manner 
that  one  would  extract  the  head  with  the  forceps,  except  that 
the  tractive  efforts  are  made   uninterruptedly  and  with   greater 


Fig.  669. — Craniotomy  on  the  after-coming  head:  one  method  of  perforating 

(Dickinson). 


force.  In  certain  cases  it  is  sufficient  simply  to  perforate  the 
skull.  This  applies  particularly  to  cases  of  hydrocephalus.  The 
head  being  evacuated,  the  forces  of  nature  are  sufficient  to  in- 
sure the  child's  delivery.  If  it  is  necessary  to  perforate  the  after- 
coming  head,  the  perforator  may  be  inserted  behind  the  ear,  in 
the  lambdoid  suture,  under  the  chin,  through  the  roof  of  the 
mouth,  or,  possibly,  through  the  foramen  magnum.  In  a  case 
of  hydrocephalus  with  breech  presentation,  should  there  be  great 
difficulty  in  reaching  the  after-coming  head,  it  is  possible  to 
evacuate  the  fluid  by  perforating  the  spinal  column  and  passing 
a  catheter  through  the  spinal  canal  into  the  cranium. 

Decapitation. — The   chief   indication  for  decapitation   is  an 
impacted  shoulder  presentation,  in  which  it  is  impossible  to  do 


EMBRYOTOMY. 


849 


version,  either  on  account  of  the  inabiHty  to  move  the  child  or 
because  of  the  risk  of  ruptured  uterus  owing  to  the  enormously 
distended  lower  uterine  segment.     The  instruments  needed  for 


Fig.  670 — Braun's  hook. 


this  operation  are  a  Braun  hook  or  a  Ramsbotham  sharp  hook. 

The  former  is  fastened  firmly  over  the  child's   neck,  when  with 

two  or  three  sharp  turns  of  the 

wrist  the  neck  is  broken,  and 

the  soft  structures  may  then  be 

pulled  through  with  the  hook 

alone,  or  may  be  severed  with 

scissors.       The     Ramsbotham 

knife-edged     hook     is     passed 

over  the  neck,  and  by  a  rocking 

motion  is  made  to  cut  through 

all  the  tissues  of  the  neck. 

In  the  absence  of  specially 
devised  instruments  for  the 
purpose,  a  string  may  be  car- 
ried over  the  neck  and  the 
child  decapitated  by  a  sawing 
movement  with  the  string,  the 
vagina  and  perineum  being  pro- 
tected by  a  Sims  speculum. 

Amputation  and  eviscera- 
tion are  very  rarely  indicated. 
Some  forms  of  monstrosities 
may  possibly  require  these 
operations.  A  long-handled 
scissors  is  the  best  instrument 
for  the  purpose. 

Cutting     or    breaking     the 
clavicles   {cleidotomy)  was  jjro- 
posed  on  theoretical  grounds  to 
secure  delivery  of  the  shoulders.     Fig.  671.— Decapitation  witii    Uraun's 
I  found  it  once  of  great  service.  ^ook  (Dickinson). 


54 


(850  OBSTETRIC   OPERATIONS. 

SYMPHYSEOTOMY. 

The  operation  of  symphyseotomy  is  a  division  of  the  pubic 
joint,  allowing  a  diastasis  of  the  bones  during  labor,  the  child 
being  extracted  through  the  natural  passage.  The  operation 
was  suggested  for  the  first  time  in  1598,  and  was  performed 
for  the  first  time  on  a  living  woman  in  1777  by  Sigault  in 
Paris.  For  a  time  symphyseotomy  was  in  high  favor,  but  the 
mortality  that  followed  it,  and  the  accidents  which  frequently 
marred  its  success,  prejudiced  the  medical  world  against  it,  and 
it  gradually  died  out.  In  1 866  the  operadon  was  revived  in  Italy, 
and  from  that  time  to  1 886  it  was  performed  7 1  times  with  a  death- 
rate  of  25  per  cent.  The  success  achieved  in  the  latter  years 
of  this  period  attracted  the  attention  of  the  Parisian  school  of 
obstetricians.  The  operation  was  revived  in  its  original  home, 
and  this  revival  was  followed  rapidly  by  its  adoption  throughout 
the  civilized  world.  In  the  following  three  years  there  were  74 
operations  in  the  United  States,  with  10  maternal  deaths  and 
18  infantile  deaths.  The  mortality  for  America  is  about  12  per 
cent,  but  certain  operators  abroad  have  had  as  many  as  20  cases 
in  succession  without  a  fatal  result,  and  in  Italy  54  symphy- 
seotomies have  been  performed  with  but  2  deaths.  It  may  be  said 
that  Cesarean  section  has  a  slightly  higher  mortahty  in  the  mother 
than  symphyseotomy  in  the  hands  of  a  surgeon  not  specially  trained, 
but  a  decidedly  higher  infantile  mortality.  The  expert  abdominal 
surgeon,  with  a  thoroughly  aseptic  technic,  should  have  a  very 
low  and  about  an  equal  maternal  mortahty  in  both  operations. 

A  separation  of  the  symphysis  up  to  7  cm.  (2I  in.)  secures  an 
increase  in  the  anteroposterior,  the  transverse,  and  the  diagonal 
diameters  of  the  pelvis  of  1.4  cm.  (0.55  in.),  3.1  cm.  (1.22  in.), 
and  3.5  cm.  (1.4  in.)  respectively.  It  is  possible  to  achieve  success 
with  a  conjugate  as  low  as  6.5  cm.  (2.56  in.),  but  in  a  pelvis  so 
badly  contracted  symphyseotomy  is  more  dangerous  than  Cesarean 
section,  and  it  is  possible  that  after  the  symphysis  is  severed  it  may  be 
found  necessary  to  deliver  the  child  by  craniotomy. 

The  indications  for  symphyseotomy  are  very  limited.  If  sec- 
tion of  the  pelvis  is  required  at  all,  pubiotomy  is  to  be  preferred. 
There  are  few  surgeons  to-day  who  perform  symphyseotomy.  I 
shall  not  do  it  again. 

The  Technic  of  the  Operation. — To  perform  the  operation  accord- 
ing to  the  Itahan  plan  the  technic  is  as  follows: 

The  abdomen  and  pubic  region  should  be  cleansed  as  though 
for  an  abdominal  section.  An  incision  is  made  just  above  the 
symphysis,  about  an  inch  long,  through  the  skin,  fat,  and  super- 
ficial fascia.     The  attachment  of  the  recti  muscles  to  the  pubic 


S  YMPHYSE  O  TO  MY. 


851 


bones  is  then  severed  by  a  transverse  cut  just  sufficient  to 
admit  the  forefinger  behind  the  symphysis.  The  forefinger  of 
the   left    hand    is    passed    behind    the    symphysis    and     hooked 


Fig.  672. — Galbiati's  knife  for  cutting  the  symphysis. 


Fig.  673. — Autlior's  knife  for  cutting  the  subpubic  ligament. 


Fig.  674. — Subcutaneous  section  of  the  sympliysis. 

under  it,  while  an  assistant  inserts  a  metal  catheter  in  the 
woman's  urethra,  holding  it  down  and  a  little  lo  one  side, 
usually  the  woman's  right.      The  curved  or  sickle-shaped  knife 


852 


OBSTETRIC   OPERATIONS. 


of  Galbiati  is  then  seized  firmly  in  the  right  hand  and  passed 
along  the  index-finger  of  the  left  hand  until  it  glides  under  the 
symphysis.  With  an  upward  and  forward  rocking  movement  of 
the  knife  the  symphysis  is  divided.  It  will  almost  invariably 
be  found  that  this  incision  has  failed  to  divide  the  subpubic 
ligament.  To  cut  this,  a  smaller  curved  knife  is  inserted  into 
the  wound  and  passed  under  the  ligament,  which  is  then  severed, 
from  below  upward,  without  difficulty.  At  this  point  in  the 
operation  there  is    usually  a  good   deal   of  hemorrhage,  which 


F'g-  675. — French  method  of  performindfesymphyseolomy  (direct  incision 


occasionally  is  most  alarming.  It  can  be  checked  at  once,  how- 
ever, by  packing  the  wound  firmly  with  a  strip  of  sterile  gauze. 
During  this  part  of  the  operation  two  assistants  hold  the  woman's 
thighs  equally  flexed  and  at  an  equal  distance  apart  from  the 
middle  line.  Eacli  assistant  should  also  support  the  pelvis  by  firm 
pressure  with  a  hand  upon  the  trochanters.  If  the  child's  head 
is  presenting,  axis-traction  forceps  should  be  applied  to  it,  and  the 
head  slowly  and  interruptedly  extracted  along  the  parturient 
canal,  at  each  tractive  effort  the  assistants  being  warned  to  exert 
firm  lateral  pressure  upon  the  pelvis  to  prevent  too  great  separa- 
tion of  the  pubic  bones,  which  would  endanger  the  integrity  of  the 
sacro-iliac  joints.  As  soon  as  the  child  is  born,  the  knees  of 
the  woman  are  brought  together  and  the  thighs  are  somewhat 
extended.     The  operator  then  removes  the  gauze  packing  from 


^  YAIPH  \  'SE  O  TOM  Y. 


853 


Fig.  676. — Author's  canvas  binder  for  symphyseotomy. 


I'ig.   677.  —  Iliiiclcr  fur  UMi  alltr  symiiliyseotoniy,  a[)[)lic(-l  and  lasltncd. 


854  OBSTETRIC   OPERATIONS. 

the  suprapubic  wound,  inserts  a  finger  behind  the  symphysis  to 
see  that  the  bladder  is  not  nipped  between  the  pubic  bones,  and 
sews  together  the  abdominal  wound  with  three  or  four  silkworm 
gut  sutures.  It  is  unnecessary  to  suture  the  pubic  bones  of  the 
symphysis.  A  dressing  of  aseptic  gauze,  cotton,  and  adhesive 
strips  is  applied  to  the  wound.  A  firm  binder  is  placed  about  the 
hips,  and  the  woman  is  put  in  bed  straight  upon  her  back,  upon  an 
even  mattress,  which  should  be  firm  enough  not  to  allow  of  sagging 
where  the  woman  hes  upon  it.  It  is  an  advantage  to  support 
the  sides  of  the  pelvis  with  sand-bags  during  the  woman's  con- 
valescence. They  should  be  placed  directly  alongside  the  hips, 
extending  at  least  to  the  knees. 

The  after-care  of  a  symphyseotomy  is  exceedingly  trouble- 
some. The  patient  must  usually  be  catheterized ;  the  vulva  and 
the  surrounding  regions  must  be.  kept  clean.  A  special  bed  has 
been  devised  for  the  after-care  of  symphyseotomy,  which  makes 
convalescence  more  comfortable  to  the  woman  and  easier  for  her 
care-takers. 

In  the  French  method  of  performing  symphyseotomy  an 
incision  is  made  directly  over  the  joint,  which  is  then  cut  with  an 
ordinary  scalpel. 

HEBOTOMY.   HEBOSTEOTOHY,   OR  PUBIOTOMY 

Section  of  the  pubic  bone  in  the  region  of  the  pubic  spine  was 
proposed  by  Gigli  in  1894  as  a  substitute  for  symphyseotomy. 
Doederlein  modified  the  operation  by  making  it  subcutaneous. 
The  idea  was  to  escape  the  injuries  to  the  bladder  and  the  infec- 
tion which  not  infrequently  followed  symphyseotomy.  A  small 
opening  is  made  above  the  pubis  in  the  region  of  the  pubic  spine 
on  the  side  toward  which  the  occiput  is  directed;  the  periosteum 
is  incised  and  pushed  back;  a  specially  constructed  ligature  car- 
rier is  passed  behind  the  pubes,  emerging  below  through  a  small 
incision  in  the  labium  majus  or  at  its  junction  with  the  labium 
minus,  or  as  far  away  from  the  vulva  orifice  as  it  can  be  made 
to  emerge  by  pulling  the  skin  toward  the  middle  line  before 
incising  it.  By  this  means  a  Gigli  saw  is  passed  upward  through 
the  first  incision  and  the  bone  is  severed.  An  immediate 
diastasis  of  i  to  \\  cm.  is  secured,  increasing  to  4  cm.  as  the 
head  passes  through  the  pelvic  canal.  Considerable  hemorrhage 
from  laceration  of  the  crus  clitoridis  is  the  rule.  After  delivery 
the  small  wounds  are  closed  with  collodion  dressing  and  the 
pelvis  is  supported  by  a  firm  binder.  Some  operators  prefer 
passing  the  saw  from  above  downward,  making  the  primary 
incision  below  instead  of  above  the  pubis.     Bumm  advocates  saw- 


CESAREAN  SECTION. 


'3D 


ing  the  bone  near  the  symphysis.  After  the  bone  is  divided  the 
delivery  may  be  spontaneous,  by  forceps,  or  by  version.  The 
limitations  of  the  operation  are  the  same  as  in  symphyseotomy. 
It  is  only  applicable  in  pelves  with  a  conjugate  diameter  of  7  cm. 
or  more.  The  necessary  precautions  about  holding  the  Hmbs  and 
preventing  too  wide  a  separation  of  the  pelvis  are  the  same  as  in 
symphyseotomy.  The  dangers  of  the  operation  are  hemorrhage, 
laceration  of  the  vagina,  injury  of  the  bladder,  infection  of  both 
the  wounds  and  the  bone,  and  failure  of  bony  union  in  the  pubis. 
One  hundred  and  forty-six  operations  are  recorded  with  eight 
deaths  (Kannegieser). 

I  would  limit  pubiotomy  to  cases  in  which  the  head  is  impacted 
low  in  the  pelvis  and  in  which  there  is  insuperable  obstruction  from 


Fig.  678. — Insertion  of  the  Doederlein  needle  and  carrier  to  place  the  Gigli  saw 

back  of  the  pubis. 

a  contracted  outlet,  only  discovered  after  labor  has  been  in  progress 
some  time  and  when  the  os  is  fully  dilated.  In  the  author's  judg- 
ment hebotomy  will  share  the  fate  of  symphyseotomy,  as  an  alter- 
native to  Cesarean  section,  becoming  obsolete  as  the  results  of 
Cesarean  section  steadily  improve.^ 


CESAREAN   SECTION'^ 
If  the  child  cannot  traverse  the  pehic  canal,  it  may  be  delivered 
by  an  abdominal  and  uterine  incision.     Cesarean  section  may  be 
performed  ante-  and  postmortem. 

1  "Zentralbl.  f.  Gyn.,"  No.  45,  1904;   "  Amer.  Jour,  of  Surgery,"  Tmie,  1906. 
^  The   name  is  not  derived  from  Ciusar,  but  from   tlie  Latin  description  of  the 
operation,  Caso  viatris  titei'o. 


856  OBSTETRIC  OPERATIONS. 

Postmortem  Cesarean  Section. — If  a  pregnant  woman  near 
term  dies  suddenly,  the  abdomen  and  uterus  may  be  cut  open  as 
quickly  as  possible,  in  order  to  deliver  a  living  infant.  It  is  said 
that  the  child  has  been  extracted  alive  twenty  minutes,  three- 
quarters  of  an  hour,  and  even  two  hours  after  the  death  of  the 
mother,  although  it  is  almost  inconceivable  that  this  should  be 
so.  The  child's  death  usually  is  synchronous  with  that  of  the 
mother,  or  follows  a  few  moments  afterward.  In  my  opinion 
rapid  version  and  extraction  preceded  by  forcible  dilatation  of  the 
cervix  is  a  preferable  method  of  delivery  in  a  woman  who  has 
died  suddenly  during  pregnancy,  and,  if  possible,  the  operation 
should  be  completed  before  death  has  actually  occurred.  Thetis- 
sues  of  the  dying  woman  offer  no  resistance  to  the  forcible  dilata- 
tion of  the  cervix,  and  the  extraction  of  the  child  can  be  effected, 
as  a  rule,  quite  as  quickly  by  version  as  by  Cesarean  section. 

Cesarean  Section  upon  the  Living  Woman. — The  first  recorded 
Cesarean  section  upon  a  living  subject  was  performed  in  Europe 
in  the  year  1610^  ;  but  the  operation  is  probably  a  much  older 
one,  and  was  in  all  likelihood  known  in  certain  primitive  tribes 
and  nations  in  remote  antiquity.  Until  quite  recent  times  the 
mortality  of  Cesarean  section  was  so  high  that  the  operation  was 
avoided  at  any  cost.  Throughout  the  civilized  world  the  mortality 
was  at  least  50  per  cent.  With  the  improvement  in  the  operative 
and  aseptic  technic  of  abdominal  surgery,  the  statistics  of  Cesarean 
section  have  steadily  improved.  Under  favorable  circumstances 
and  in  the  hands  of  skilful  operators,  the  mortality  of  Cesarean  sec- 
tion should  be  below  5  per  cent. 

Varieties  of  the  Cesarean  Section. — In  1876  Porro "  modified 
the  operation  by  successfully  performing,  in  addition  to  the  celio- 
hysterotomy,  a  hysterectomy.  The  stump  was  fixed  in  the  ab- 
dominal wound  and  treated  extraperitoneally.  The  improve- 
ment introduced  by  Porro  reduced  the  m.ortality  one-half  by  the 
prevention  of  leakage  through  the  uterine  wound  into  the  abdomi- 
nal cavity. 

The  next  improvement  in  the  technic  was  introduced  by 
Muller,  who  advocated  a  long  abdominal  incision  through  which 
the  womb  was  delivered  before  it  was  incised.^  This  prevented 
the  soiling  of  the  peritoneal  cavity  by  liquor  amnii  and  blood. 
Muller  also  advocated  the  application  of  an  Esmarch  tube  around 
the  cervix  and  broad  ligaments  to  control  hemorrhage,  but  this 
is  a  bad   plan,   as  it  predisposes  to  postpartum  bleeding  from 

•  By  Trautmann  in  Wittemberg.     The  patient  lived  twenty-five  days. 

'''The  amputation  of  the  uterus  after  a  Cesarean  section  was  first  proposed  by 
Michaelis  in  1809,  and  first  carried  out  with  a  fatal  result  by  Storer,  of  Boston,  in 
1868. 


CESAREAN  SECTION.  857 

relaxation  of  the  womb,  and  is  never  really  necessary.  No  con- 
striction of  the  cervix  at  all  is  required  if  the  operation  is  done 
with  sufficient  rapidity. 

The  most  important  modification  of  Cesarean  section  in  recent 
times  was  introduced  by  Sanger/  who  was  the  first  to  propose 
the  careful  and  accurate  closure  of  the  uterine  wound  by  a  double 
layer  of  sutures.  At  first  it  was  thought  necessary  to  make  a  peri- 
toneal flap  by  exsecting  a  portion  of  the  uterine  muscle  below  the 
peritoneum.  But  it  was  soon  recognized  that  this  is  unnecessary, 
and  the  present  practice  is  to  use  simply  deep  and  superficial  layers 
of  sutures,  sufficiently  large  in  number  to  secure  the  accurate  and 
firm  closure  of  the  uterine  wound.  A  single  insertion  of  the  needle 
on  each  side  of  the  wound  insures  the  approximation  and  closure 
of  the  peritoneal  covering  of  the  wound. 

Indications  for  Cesarean  Section. — The  indications  for  this 
operation  are  relative  and  absolute. 

By  an  absolute  indication  is  meant  some  condition  which 
admits  of  no  other  method  of  delivery.  Examples  are  furnished 
in  extreme  degrees  of  pelvic  contraction — in  a  flat  pelvis,  for 
instance,  in  which  the  true  conjugate  is  less  than  6.5  cm.  (2.56 
in.).  The  highest  grades  of  kyphosis,  osteomalacia,  spondylo- 
listhesis, and  Naegele's  pelves  also  furnisli  absolute  indications 
for  Cesarean  section,  as  do  foreign  growths  obstructing  the 
pelvis,  cicatricial  contraction  of  the  vagina,  and  carcinoma  of 
the  cervix  and  of  the  rectum. 

By  a  relative  indication  for  Cesarean  section  is  meant  a  con- 
dition that  admits  of  some  other  method  of  delivery, — say,  by 
pubiotomy,  forceps,  version,  or  by  craniotomy, — -but  in  which  the 
question  arises  whether  Ceserean  section  will  not  give  the  best 
result  for  mother  and  child.  Examples  of  a  relative  indication 
for  Cesarean  section  are  found  in  flat  pelves  with  a  true  conjugate 
above  seven  centimeters. 

Technic  of  the  Porro  Operation  or  Celiohysterectomy. — The 
most  favorable  time  for  a  Cesarean  section  is  about  two  weeks 
before  term.  It  is  not  necessary  to  wait  for  the  beginning  of 
labor;  in  fact,  it  is  better  not  to  do  so  if  the  indication  for  the 
operation  is  absolute.  A  time  of  day  convenient  to  the  physi- 
cian should  be  selected,  and  all  the  preparations  should  be  made 
for  the  operation  as  for  any  other  abdominal  section.  In  addition, 
there  should  be  a  painstaking  cleansing  of  the  \uha  and  vagina, 
and  the  latter  should  be  packed  with  sterile  gauze  immediately 
before  the  abdominal  section. 

The  Operation. — With   a  large   scalpel  hekl   firmly  in   the  full 

^  "  Archiv  f.  Gyn.,''  Bd.  xix. 


858  OBSTETRIC   OPERATIONS. 

hand,  a  free  incision  is  made  from  two  inches  above  the  umbilicus 
to  just  above  the  symphysis.  This  incision  may  be  carried  en- 
tirely through  the  abdominal  wall  in  its  upper  part,  as  the  intes- 
tines are  out  of  the  way.  The  abdominal  opening  is  enlarged 
with  scissors  downward  as  low  as  possible.  An  assistant  makes 
the  wound  gape  while  the  operator  delivers  the  womb  from  the 
abdominal  cavity.  A  large  intestinal  gauze  pad  is  next  packed 
in  the  peritoneal  cavity  behind  the  uterus,  and  two  other  gauze 
pads  are  packed  between  the  uterus  and  the  sides  of  the  incision. 
The  assistant  then  approximates  the  edges  of  the  abdominal  wound 
as  closely  as  possible  around  and  above  the  cervix,  at  the  same 
time  squeezing  the  latter  with  his  outspread  hands.  With  a  few 
rapid  but  light  strokes  of  the  knife  the  operator  makes  an  incision 
through  the  uterine  muscle,  but  not  through  the  membranes,  long 
enough  to  permit  the  delivery  of  the  child.  Then,  by  the  fingers  of 
the  left  hand,  the  uterine  wall  is  opened  into  the  uterine  cavity, 
the  membranes  are  ruptured,  the  placenta,  if  in  the  way,  is  de- 
tached and  pushed  aside,  the  child  is  seized  by  the  most  accessible 
part, — shoulder  or  leg, — is  deli^•ered,  and,  with  the  placenta  still 
attached  to  it,  is  dropped  into  a  sterile  sheet  spread  out  over  the 
outstretched  arms  of  an  assistant  who  stands  directly  at  the  opera- 
tor's left  hand,  and  whose  duty  it  is  to  revive  the  child,  if  asphyxi- 
ated, and  to  tie  and  cut  the  cord.  Up  to  this  point  the  operation 
rarely  requires  seventy-five  seconds.  Then,  if  the  Porro  operation 
is  performed,  follows  an  easy  hysterectomy:  the  ligation  of  the 
ovarian  arteries  and  of  the  arteries  of  the  round  ligaments;  the 
application  of  clamps;  the  cutting  of  the  broad  ligaments;  the  prep- 
aration of  peritoneal  flaps;  amputation  of  the  womb;  the  ligation 
of  the  uterine  arteries;  and  the  oversewing  of  the  stump,  which  is 
dropped. 

The  technic  of  the  Sanger  operation  is  the  same  up  to  the  point 
when  the  child  and  appendages  have  been  extracted  from  the  womb. 
Then,  instead  of  amputating  the  uterus,  the  uterine  wound  is  care- 
fully brought  together  by  three  sets  of  sutures;  one  interrupted, 
of  fine  Pagenstecher  thread,  set  about  an  inch  apart,  inserted  under 
the  peritoneum  running  across  the  lower  part  of  the  wound  above 
the  endometrium  and  emerging  on  the  opposite  side  under  the 
peritoneum;  the  second,  a  running  catgut  (chromicized)  stitch  in 
two  tiers,  embracing  the  muscle  only  and  ending  opposite  the  point 
where  it  began,  so  that  there  is  but  one  knot;  the  third,  a  continuous 
stitch  of  catgut  in  the  peritoneum,  beginning  above  and  running 
down,  the  needle  being  inclined  upward  at  each  insertion  to  allow 
for  the  pull  downward  of  the  suture  when  it  is  tightened,  and  coming 
back  again  to  the  top  of  the  wound,  making  an  interlacing  suture 
(Figs.  679  and  680). 


CESAREAN  SECTION. 


859 


Fig.   679. — A,  The  interrupted  sutures ;    B,  the  lower  tier  of  the   running  catgut 

stitch. 


A 

B 

W 

^ 

:^^^ 

p^     0!i 

jEf.              ,  1 

^^ 

I ' 

\  7 

T 

\j 

r 

\j 

/ 

Fig.  680. — A,  The  upper  tier  of  the  running  catyut  stitch  ;  B,  the  running  stitch 
in  the  peritoneum,  which  goes  up  again  to  where  it  l^egan,  the  needle  heing  inserted 
between  the  punctures  made  coming  down,  and  there  being  but  one  knot  on  the  peri- 
toneal surface  above  the  upper  angle  of  the  wound.  The  completed  stitch  is  like  a 
shoe-lace. 


,86o  OBSTETRIC   OPERATIONS. 

Fritsch's  proposition  to  make  the  incision  across  the  fundus 
uteri  from  tube  to  tube,  instead  of  in  the  anterior  abdominal  wall, 
has  received  a  trial  in  Germany.^  There  is  no  decided  advantage 
in  it  except  that  the  uterine  wound  is  as  far  as  possible  from  the 
cervical  canal,  and,  therefore,  from  subsequent  contamination. 
It  is  also  a  little  easier  in  the  fundal  incision  to  enucleate  the  uterine 
end  of  the  tubes  and  thus  to  prevent  future  conceptions.  But 
should  leakage  occur,  the  woman  is  deprived  of  a  safeguard  to 
which  she  has  often  owed  her  life,  namely,  adhesions  between 
the  uterine  and  abdominal  walls,  and  the  incision  is  made  in  that 
portion  of  the  uterus  most  subject  to  spontaneous  rupture  in  sub- 
sequent pregnancies.  Therefore,  the  fundal  incision  is  not  recom- 
mended. 

The  Choice  of  Celiohysterectomy  or  of  Celiohysterotomy  in 
a  Case  Requiring  Cesarean  Section. — The  classical  conservative 
Cesarean  section,  or  cehohysterotomy,  is  a  safer  and  better  opera- 
tion than  the  Porro-Cesarean  section,  or  ceHohysterectomy — the 
removal  of  the  uterus  after  the  extraction  of  the  child.  Hysterec- 
tomy should  only  be  performed  when  a  woman  has  been  very  long 
in  labor  and  many  futile  attempts  to  extract  the  child  have  been 
made,  probably  infecting  the  endometrium;  if  there  is  uncontrol- 
lable hemorrhage  from  uterine  atony;  in  case  of  insuperable  ob- 
stacle to  drainage  of  the  lochia,  as  a  cancer  of  the  cervix  or  a  bony 
tumor  of  the  pelvis;  or  in  the  presence  of  a  uterine  tumor  which 
could  only  be  removed  with  the  uterus. 

If  Cesarean  section  is  performed  for  a  relative  indication,  and 
it  is  possible  in  future  labors  for  the  patient  to  be  delivered  without 
a  repeated  section,  the  Sanger  operation  is  obviously  indicated. 

In  view  of  the  improved  results  of  the  operation,  there  is  no 
objection  to  a  repeated  Cesarean  section,  so  that  it  is  not  unjusti- 
fiable to  allow  a  woman  to  become  pregnant  again,  even  with  the 
certainty  of  a  repeated  section.^ 

The  author's  experience  in  Cesarean  section  amounts  to  "^t^ 
operations,  performed  for  the  following  indications:  fibroid  tumors, 
2;  dermoid  cysts  impacted  in  pelvis,  2;  cancer  of  the  cervix,  i; 
partial  atresia  of  vagina,  2;  cornual  pregnancy,  i;  impacted 
shoulder  presentation,  2;  contracted  pelves,  73,  of  which  there 
were  2  kyphotic  pelves,  2  obliquely  contracted  and  flat,  i  trans- 

'  Hiibl  has  collected  51  cases  of  fundal  incision  according  to  Fritsch's  method, 
"Monatschr.  f.  Geb.  u.  Gyn.,"  Bd.  x,  p.  417.  A  case  is  reported  as  spontaneous 
rupture  of  the  uterus  in  a  subsequent  pregnancy.  (Ekstein,  "  Zentralbl.  f.  Gyn.," 
No.  44,  1904.) 

^  "  Repeated  Cesarean  Sections,"  Haven  and  Young,  "  Am.  Jour,  of  Obstetrics," 
October,  1903  ;  also,  "  Annales  de  Gyn.,"  Oct.,  1904,  p.  577.  In  175  operations  in 
Schauta's  Clinic  there  were  18  repeated  sections.  Neumann,  "Arch.  f.  Gyn.,"  lid. 
Ixxix. 


CESAREAN  SECTION.  86 1 

versely  contracted,  2  justo-minor  and  66  flat  rachitic.  Among  this 
number  it  was  necessary  to  perform  a  Porro  operation  in  14  cases. 
In  7  of  the  operations  for  contracted  pelvis  the  patient  had  been 
in  labor  many  hours.  Futile  attempts  at  delivery  had  been  made 
with  forceps,  and  in  two  instances  by  craniotomy.  The  uterus 
was  already  infected  and  the  birth-canal  injured  by  slipping  in- 
struments or  by  the  exercise  of  unjustifiable  force  in  efforts  at 
extraction.  In  one  of  the  cases  of  impacted  dermoids  the  woman 
had  been  in  labor  four  days.  The  pelvic  connective  tissue  and 
lower  uterine  segment  were  extraordinarily  edematous  and  the 
endometrium  was  almost  black  in  color.  In  the  two  cases  of 
fibroids  attached  to  the  lower  uterine  segment  a  hysterectomy  was 
necessary  to  remove  the  tumors.  In  the  cases  of  atresia  of  the 
vagina  and  of  cancer  of  the  cervix  it  was  obviously  improper  to 
leave  the  womb  behind. 

It  appears  that  a  Porro  operation  is  required  in  practice  about 
one-sixth  as  often  as  the  conservative  Cesarean  section.^ 

Extraperitoneal  Cesarean  Section. — Frank  ^  has  revived  the 
old  idea  of  Joerg  and  Ritgen,  to  make  a  transverse  incision  over  the 
symphysis,  to  push  up  the  peritoneal  reduplication,  and  to  incise 
the  lower  uterine  segment  below  it.  It  remains  to  be  seen  if  a 
better  aseptic  technic  makes  this  operation  justifiable.  American 
surgeons  who  remember  the  results  of  laparo-elytrotorny  will  be  loth 
to  attempt  it.  The  operation  is  only  justifiable  in  case  of  long- 
continued  labors  with  infection  of  the  birth-canal.  Personally  I 
would  prefer  a  Porro  operation  in  such  cases. 

1  Leopold  in    100  Cesarean  sections  performed  the  Porro  operation  twenty-nine 
times  ;  Ueber  100  Sectiones  CcesareEe,  "Arch.  f.  Gyn.,"  Bd.  Ivi. 
^"Zentralbl.  f.  Gyn.,"  No.  36,  1906. 


CHAPTER  III 

Operations  for  the  Complications  and  the  Pathological  Conse- 
quences of  the  Child-bearing:  Process 

The  preparation  of  the  patient  and  the  room  has  already  been 
described.  The  dressings  in  the  autoclave  in  hospital  work  are  as 
follows : 

Dressings  and  the  Packing  of  the  Autoclaves.— The  cage  of 
one  autoclave  is  packed  from  the  bottom  up  with  the  following 
materials  in  regular  order  for  an  abdominal  section : 

Packing  Cage  for  Autoclave  No.  1 . — Four  pieces  absorbent  cotton ; 
12  pieces  of  gauze;  i  book  of  silver  foil;  12  towels;  2  tubes  of 
Pagenstecher's  thread;  i  glass  tube  tilled  with  6-inch  gauze  band- 
age for  packing;  also  a  3-inch  rolled  bandage;  4  sheets;  3  gowns; 
3  caps,  or  squares  of  gauze  for  the  head;  3  nail-brushes.  This 
cage  is  subjected  to  three  sterilizations  on  three  successive  days. 
A  cage  is  always  kept  packed  that  has  had  two  sterilizations  at 
240°  F.  for  forty  minutes  for  emergency  operations.  It  is  again 
sterilized  immediately  before  the  operation. 

The  second  autoclave  without  a  cage  is  packed  from  within 
outward,  as  follows: 

Autoclave  No.  2. — Three  small  basins;  i  package,  wrapped  in 
gauze,  containing  15  pads  for  sponges;^  3  large  abdominal  pads 
with  tape  on  the  corner;  i  dozen  butterfly  8-ounce  sponges;  i  pan 
for  sutures  and  needles;  2  small  white  enameled  pitchers;  i  tube  of 
catgut;  3  nail-brushes;  small  jar  of  olive  oil  for  Downes's  clamps; 
2  rubber  sheets  to  cover  the  glass  table  with. 

The  gauze  pads  are  provided  in  an  invariable  number.  By 
using  an  invariable  number  the  nurse  who  prepares  the  package 
has  no  excuse  for  a  mistake  in  this  respect,  and  by  making  this 
number  as  small  as  practicable,  time  and  trouble  are  saved  in  the 
final  count  of  the  pads. 

For  a  plastic  operation  the  following  articles  are  omitted  from 
the  autoclaves:  From  No.  i,  the  abdominal  binder,  tubes  of  silk, 
pieces  of  gauze,  and  the  silver  foil;  a  fenestrated  sheet  is  added. 
From  No.  2,  the  gauze  pads.  For  plastic  operations  sea  sponges 
are  preferable  and  are  safe  if  soaked  over  night  in  a  i :  1000  sub- 
limate solution.     They  are  used  once  only. 

'  These  packages  of  pads  have  had  two  previous  sterilizations  and  are  kept  stored 
in  sterile  glass  jars. 

862 


DUESSnVGS  AND   PACKING    OF  AUTOCLAVES.  863 


I- — Protection  of  field  of  operation  by  sterile  towels. 


Fig.  6S2.— A  sheet  of  rubber  clam  over  the  buttocks  tied  with  tape  to  the  uprights  of 
the  table,  with  a  slit  corresponding  wiih  the  vulvar  orifice. 


864  OBSTETRIC   OPERATIONS. 

In  private-house  operations  the  patient  is  given  a  hst  of  the 
articles  to  provide  as  follows: 

For  Plastic  Operations. — One  250-gram  can  Squibb's  ether  (un- 
opened); I  pint  alcohol;  8  ounces  tincture  of  green  soap;  i  pound 
absorbent  cotton;  5  square  yards  sterilized  gauze;  3  small  sea 
sponges  (size  of  lemon),  to  be  soaked  over  night  in  a  i :  1000  bi- 
chlorid  solution;  i  bottle  bichlorid  tablets;  i  square  yard  iodo- 
form gauze  (5  per  cent.). 

For  Abdominal  Section. — One  2  5o-gra,m  can  Squibb's  ether 
(unopened);  i  quart  alcohol;  i  pint  tincture  green  soap;  i  pint 
benzine;  i  quart  i  per  cent,  formalin;  i  bottle  bichlorid  tablets;  4 
ounces  collodion;  2  ounces  carbolic  acid  (pure);  i  roll  3-inch  Z.  O. 
adhesive  plaster;  i  pound  absorbent  cotton;  5  square  yards  ster- 
ihzed  gauze.  If  plastic  also,  add  i  square  yard  iodoform  gauze 
(5  per  cent.)  and  3  small  sea  sponges,  soaked  over  night  in  a 
1 :  1000  bichlorid  solution. 

The  operator  carries,  in  addition  to  his  instruments,  a  bag  con- 
taining the  following  articles :  Nest  of  6  basins,  sterilized ;  4  brushes, 
sterilized;  6  pair  of  gloves,  sterilized;  douche  bag,  sterilized;  4- 
ounce  bottle  of  sterilized  glycerin;  4-ounce  bottle  of  sterihzed  al- 
cohol; I  steriHzed  razor;  i  bottle  of  sterihzed  normal  salt  tablets; 
bag  of  cotton  balls;  chloroform  mask;  bottle  of  chloral  chloroform; 
small  can  of  ether;  3  ounces  of  collodion;  3-ounce  bottle  of  pure 
carbolic  acid;  i  square  yard  of  iodoform  gauze  (unopened);  i 
bottle  of  bichlorid  tablets;  i  sterile  hypoderm.oclysis  needle. 

For  all  vaginal  operations  the  patient  is  arranged  in  the  dorsal 
position,  with  the  legs  co\'ered  by  sterilized  leggings,  supported  by 
Edebohls'  leg  supports.  The  field  of  operation  is  either  sur- 
rounded by  sterile  towels  (Fig.  681)  or  protected  by  rubber  dam 
(Fig.  682). 

Operationsonthe  vulva  are  for  perineovaginal  fistula;  vaginis- 
mus; imperforate  or  resisting  hymen;  agglutination  of  the  labia; 
exsection  of  the  five  pairs  of  vulvar  nerves;  exsection  of  neo- 
plasms. 

Perineovaginal  fistula,  the  result  of  a  central  tear  or  perforation 
of  the  perineum,  is  treated  by  inserting  a  scissors  blade  in  the  sinus, 
slitting  the  perineum  into  the  vagina,  denuding  the  granulations 
along  the  sinus  tract,  and  uniting  the  wound  with  sutures. 

Vaginismus,  a  possible  cause  of  steriHty,  if  it  does  not  yield  to 
gradual  dilatation  or  to  the  electrocauterization  of  painful  papillae, 
is  treated  by  incising  the  perineal  body  and  carrying  the  incisions 
up  to  the  posterior  vaginal  sulci,  in  imitation  of  the  commonest 
form  of  laceration  in  labor.  Interrupted  sutures  unite  skin  and 
mucous  membrane,  but  do  not  include  muscle  or  fascia. 

Imperforate  or  resisting  hymen  requires  exsection  of  the  hymen 


OPERATIOXS   ON  THE    VULVA. 


865 


by  cutting  it  with  scissors  around  its  base.     The  narrow  wound 
left  is  closed  with  interrupted  catgut  sutures. 

Agglutination  of  the  labia  is  usually  seen  only  in  young  infants, 
but  may  persist  to  adult  life.  A  blunt  dissection  separates  the 
labia.     If  a  raw  surface  remains  it  is  covered  by  suturing,  or  else 


Fig.  683. — Y'Shaped  incision  through  the  levator  ani  muscles  and  the  perineum  for 

vaginismus. 


Fig.  684. — Insertion  of  the  sutures  in  the  operation  for  vaginismus. 

a  light  pack  keeps  the  labia  apart  till  tlie  abraded  surfaces  are  healed 
(Fig.  685). 

Exsection  of  the  vulvar  nerves  is  reriuired  in  the  worst  cases  of 
pruritis  resisting  all  other  treatment.  Four  incisions  are  made: 
two  parallel  with  the  ascending  ramus  of  the  ischium,  two  over 
Poupart's  ligament.  Through  the  first  the  long  pudendal  nerves 
are  exsected,  as  large  a  segment  as  possible  being  pulled  out. 
5.S 


866 


OBSTETRIC   OPERATIONS. 


After  opening  the  triangular  ligament,  the  terminal  branches  of  the 
pudic,  the  perineal  nerve,  and  the  nerve  of  the  dorsum  of  the  clitoris 
are  removed.  Through  the  second  incision  the  genitocrural  and 
the  ilio-inguinal  nerves  are  removed. 


Fig.  685. — Agglutinated  labia  in  infant :    I,  Before  separation;   2,  afterward. 


Fig.  686. — Steps  in  operation  for  elephantiasis. 

Amputation  of  the  labia  and  clitoris ;  removal  of  the  inguinal 
glands  is  required  for  the  removal  of  malignant  growths.  The 
incisions  and  closure  of  the  wounds  are  shown  in  Fig.  686. 

The  same  technic,  without  the  inguinal  section,  is  required  for 


OPERATIONS    ON   THE    VAGINA.  86/ 

elephantiasis  vulvae.  The  removal  of  polypoid  and  sessile  tumors 
of  the  vulva  present  no  difficulties,  as  a  rule,  though  control  of  the 
hemorrhage  in  the  latter,  if  large,  may  be  awkward. 

Operations  on  the  vagina  are  required  for  lacerations  of  the 
posterior  wall,  including  the  perineum,  possibly  the  sphincter  ani 
and  the  rectovaginal  septum;  rectovaginal  fistulae;  lacerations  and 
injuries  of  the  anterior  wall,  including  urinary  fistulae;  for  accjuired 
stenosis  and  atresia  of  the  vagina;  vaginal  sections  for  opening  the 
vaults. 

Lacerations  of  the  posterior  wall,  like  all  the  lacerations  of 
the  genital  canal,  are  best  repaired  a  week  after  labor,  under  an 
anesthetic,  on  an  operating  table,  with  sufficient  assistance  and 
implements,  exactly  as  in  a  secondary  operation:  The  labia  are 
seized  with  AlUs'  forceps  at  the  level  of  the  lowest  carunculae  myr- 
tiformes.  A  guide  stitch  is  placed  in  the  posterior  vaginal  wall 
directly  under  the  external  urinary  meatus.  By  pulling  one  Allis 
forceps  and  the  guide  stitch  in  opposite  directions  outward  and 
downAvard,  the  posterior  sulcus  is  exposed;  denudation  is  required, 
even  in  a  recent  tear,  for  a  part  of  it  is  always  submucous.  The 
other  sulcus  is  exposed  and  denuded.  Then  by  holding  the  guide 
stitch  upward  in  the  middle  line  and  pulling  the  forceps  apart  the 
mucous  membrane  between  the  sulci  is  denuded  or  freshly  torn 
surfaces  covered  with  granulation-tissue  are  scraped  with  the  edge 
of  a  knife.  The  ruptured  levator  ani  muscle  in  the  posterior  sulci 
is  united  with  a  double  tier  suture  of  chromic  gut,  two  half-hitches 
being  taken  in  the  stitch  as  it  turns  upward  after  coming  down 
from  the  apex  of  the  wound,  in  its  deeper  portion  to  the  base. 
One  knot  at  the  apex  of  the  sulcal  denudation  secures  the  stitch. 
The  retracted  ends  of  the  transversus  perinei  and  bulbocavernosus 
muscles  are  brought  together  by  silkworm  sutures,  which  are  in- 
serted by  the  technic  represented  in  Fig.  693.  Finally,  a  single 
stitch  at  the  top  of  the  perineal  wound  unites  the  posterior  com- 
missure of  the  vulva,  restoring  the  fossa  navicularis.  The  perineal 
stitches  are  knotted;  they  are  removed  on  the  twelfth  day. 

If  the  operator  prefers  the  older  method  of  an  immediate  ojjer- 
ation  the  sutures  may  be  inserted  as  represented  in  Figs.  695-699. 
This  method,  however,  does  not  give  as  good  results  in  the  repair 
of  the  genital  canal  as  the  intermediate  operation  at  the  end  of  a  week. 

Lacerations  of  the  sphincter  ani  can  ])e  successfully  repaired 
almost  without  exception  by  the  following  technic.  Any  one 
who  must  confess  to  as  much  as  5  per  cent,  failures  has  not  yet 
learned  how  to  perform  the  operation : 

The  sphincter  ani  is  seized  between  the  forefmger  and  thumb 
of  both  hands  and  thoroughly  stretched.  The  denudation  is 
made  so  as  to  expose  the  retracted  ends  of  the  muscle.    Two  good- 


OBSTETRIC   OPERATIONS. 


Fig.  687. —  1  he  Liiimct  opeiation  :  a,  1  hi  jjUiu.  butuie  on  the  crest  of  the 
rectocele  and  the  forceps  at  the  level  of  the  lowermost  carunculEe  myrtiformes ; 
b.  marking  with  scissors  the  area  to  be  denuded  in  the  left  sulcus. 


Fig.  688. — The   Emmet  operation  :   c.  Denuding  the  left  sulcus  ;   d,  cutting  off  the 
flap  of  vaginal  wall  made  by  denuding  the  left  sulcus. 


OPERATIONS   ON  THE    VAGINA. 

f 


869 


Fig.  689. — The  Emmet  operation  :    ,-,  J  denuding  the  right  sulcus;  f,  denuding  the 
triangular  area  between  the  sulci. 


Fig.  690. — The  Emmet  oijcralion  :  t;.  Dissecting  and  removing  the  third  trian- 
gular flap  from  the  crest  of  the  rectocele  to  tlie  base  of  the  perineal  tear ;  h,  the 
denudation  completed. 


8/0 


OBSTETRIC   OPERATIONS. 


sized  tenacula  are  hooked  deeply  in  the  muscle  and  its  ends  are 
brought  into  plain  sight.     They  are  easily  recognized,  being  a 


Fig.  691.  —  Figure-of-eight  suture  lor  the  sphincter  ani  in  complete  lacerations  of  the 

perineum. 
i  j 


Fig.  692. — The  Emmet  operation  :    Continuous  two-tier  suture  of  the  posterior  sulcus 
for  lacerations  of  the  levator  ani  muscle. 

lighter,  yellowish  red,  contrasted  with  the  deep  red  of  the  tissues 
around  them.  Two  or  at  most  three  figure-of-eight  stitches  of 
silkworm  gut  are  inserted,  begininng    and  ending  in  the  vagina. 


OPERATIONS   ON  THE    VAGINA, 
k  I 


871 


1  i,^'-  ''9,v  'i  1"'  1-iiiiiiel  operation  :  k,  The  insertion  of  the  crown  stitches  by 
a  back-handed  stroke  on  the  right  side  which  catches  the  retracted  end  of  the 
transversus  perinei  muscle ;  /,  by  forcible  traction  on  the  edges  of  the  vulvar 
wound  the  needle  catches  more  firmly  the  retracted  ends  of  the  transversus  perinei 
muscles  and  the  stitch  is  continued  in  the  usual  manner  from  right  to  left. 


Fig.  694. — The  Emmet  operation :  Perineal  sutures  joining  the  transverse  perineal 
muscles  and  the  perineal  body  in  the  middle  line. 


8/2 


OBSTETRIC   OPERATIONS. 


Fig.    695. — Vaginal  sutures    for  the       Fig.  696. — Perineal    sutures  for    lacera- 
repair  of  a  laceration  through  the  perineal  tion  of  *£he  perineal  body, 

bodv. 


F'g-  697. — Vaginal  and  perineal  sutures  Fig.  69S. — Vaginal  and  perineal  su- 

for  laceration  of  the  perineal  body.  tures  for  laceration  of  the  posterior  vagi- 

nal sulci  and  of  the  perineal  body. 


OPERATIONS    ON   THE    VAGINA. 


^71 


Fig.  699. — Vaginal  and  perineal  su-  Fig.   700. — Rectal  and  anal  sutures  in  a 
tores  for  an  extensive  tear  involving  the  complete  tear  of  the  perineum, 

whole   length  of  the  perineum  down  to 
the  anus. 


Fig.   701. — The  sutures  for  a  complete  laceration  of  the  perineum  in  either  a  primary 
or  a  secondary  operation  :  A,  A,  the  harrier  or  splint  stitch. 


874 


OBSTETRIC   OPERATIONS. 


In  the  turn  that  catches  the  muscle  a  deep  insertion  is  made.  These 
stitches  are  shotted  in  the  vagina.  The  remainder  of  the  perineal 
or  pelvic  floor  laceration  is  repaired  as  usual.  The  advantage  of 
the  figure-of-eight  stitch  is  that  the  sutures  are  more  easily  removed. 
They  may,  however,  be  inserted  from  the  rectal  side  and  knotted 
in  the  rectum,  with  a  greater  certainty  of  permanent  union.  The 
bowels  are  kept  fluid  for  tw^o  weeks  by  Carlsbad  water  and  Sprudel 
salts.    The  stitches  are  removed  on  the  fourteenth  day. 


Fig.  702. — Denudation  of  the  anterior  vaginal   sulcus  for  submucous  laceration  of  the 
muscle  and  fascia  of  the  urogenital  trigonum. 


If  the  rectovaginal  septum  is  torn.,  it  is  united  after  a  flap-split- 
ting denudation  by  a  two-tier  suture  of  chromic  gut,  beginning 
and  ending  in  the  vagina. 

Lacerations  of  the  anterior  vaginal  wall  occur  in  the  anterior 
vaginal  sulci,  involving  the  muscle  and  fascia  of  the  urogenital 
trigonum,  the  only  support  of  the  lower  third  of  the  anterior  vaginal 
wall.  They  are  repaired  by  a  triangular  denudation,  for  they  are 
almost  always  submucous,  and  a  two-tier  chromic  gut  suture  (Figs. 


OPERATIONS   ON   THE    VAGINA. 


87 


/D 


702,  703).  If  these  injuries  are  neglected  and  a  cystocele  results,  two 
other  factors  must  be  taken  into  account  in  the  damage  sustained 
by  the  anterior  vaginal  wall  in  labor:  the  separation  of  the  fascial 
plates  under  the  vaginal  wall  and  the  pull  of  the  uterovesical  liga- 
ment on  the  bladder.  The  cystocele  may  be  permanently  cured 
by  the  following  technic:  A  T-shaped  incision  through  the  vaginal 
wall  and  dissection  of  the  flaps  exposes  the  bladder,  which  is  com- 
pletely separated  from  the  vagina  by  Goffe's  dissector.     The  utero- 


^fe>-. 


Fig.  703. — Junction  of  the  urogenital  trigonum  muscle  by  a  two-tier  catgut  suture. 


vesical  ligament  is  cut.  The  bladder  is  pushed  up  into  the  ])eh'is. 
The  strong  fascial  plates  are  caught  by  curved  needles  and  brought 
together  in  the  middle  line  by  mattress  sutures  of  chromic  gut, 
each  insertion  of  the  needle  being  from  aljo\'e  downward.  The 
vaginal  wall  is  united  by  interruj^ted  sutures,  but  is  not  relied  u])on 
for  support.  A  formal  cystocele  operation  may  be  performed  two 
weeks  after  childbirth  (Figs.  704-709). 

Fistulas  between  the  genital  and  urinary  canals  are  usually 


8^6 


OBSTETRIC   OPERATIONS. 


the  result  of  pressure-necroses  following  labor.  They  are  becoming 
very  rare  in  all  civilized  countries  in  which  women  receive  proper 
attention  in  parturition.  It  is  a  question  w^hether  more  are  not 
encountered  to-day  from  injuries  in  gynecologic  operations,  es- 
pecially in  hysterectomy  for  cancer  of  the  cervix.^  A  neglected 
pessary  sometimes  ulcerates  through  the  vesicovaginal  septum. 
Other  causes  are  fractured  pelvis,  injury  of  the  vagina  in  attempts 
at  criminal  abortion,  ulcerations  through  the  vaginal  wall  of  a  vesi- 


Fig.  704. — Operation  for  cystocele.      Incision  in  anterior  vaginal  wall. 


cal  calculus  or  of  a  foreign  body  inserted  in  the  bladder,  injury  to 
the  bladder-wall  in  anterior  vaginal  fixation  of  the  uterus,  anterior 
colporrhaphy,  symphysiotomy,  pubiotomy,  or  myomectomy,  and 
in  obstetrical  operations,  such  as  the  use  of  blunt  hooks,  attempts 
at  version,  clumsy  insertion  of  the  forceps,  forcible  extraction  of 
the  head  past  a  prolapsed  cystocele,  and  craniotomy. 

'  In  the  beg^inning  of  mv  practice  I  .saw  several  vesicovaginal  fistula;  a  year  fol- 
lowing labor.      Now  I  see  about  one  a  year. 


OPERATIONS   ON   THE    VAGINA. 


877 


The  fistulae  following  pressure-necroses  in  a  prolonged  labor 
are  easily  avoidable  by  the  proper  and  timely  use  of  the  forceps 
or  by  the  other  obstetric  operations  that  may  be  indicated  in 
an  insuperably  obstructed  labor.  In  more  than  15,000  women 
dehvered  in  the  hospital  services  with  which  the  author  is  con- 
nected there  has  not  been  a  single  urinary  fistula  following  labor, 


Fig-  705. — Separating  bladder  from  vagina  with  Goffe"s  dissector. 


but  a  few  are  referred  to  his  clinics  from  year  to  year,  deli\-ered 
elsewhere. 

Urinary  fistulae  may  be  classified  as  follows:  vesicovaginal 
fistula;;  vesicovestibular  fistulae,  uterovesicovaginal  fistuke — (a) 
superficial,  through  the  anterior  lip  of  the  cervix,  which  forms  the 
upper  wall  of  the  sinus,  and  [h)  deej),  through  the  uterine  wall,  the 
anterior  Up  of  the  cervix  having  sloughed  off;  uterovcsical  fis- 
tulae; urethral  fistulae;  enterovesical  fistula-;  colovesical  fistulae; 
ureterovaginal  and  uretero-uterine  fistulae. 

The  opening  into  the  bladder  varies  in  size  and  shape  from  a 


878 


OBSTETRIC   OPERATIONS. 


pin-point  orifice  to  a  defect  of  the  whole  base  of  the  bladder,  and 
from  a  round  hole,  regular,  as  if  punched  out  with  an  instrument, 
to  a  jagged  opening  usually  running  across  the  vagina,  with  off- 
shoots running  up  the  anterior  sulci  or  in  the  median  line.  The 
vesical  mucous  membrane  may  prolapse  through  a  large  opening. 


Fig.  706. — Cutting  the  uteiovesical  ligament. 

Irritated  by  discharges  and  attrition,  it  becomes  hypertrophied 
and  inflamed. 

The  urethra  is  often  wanting  in  its  upper  part  and  its  canal 
may  be  obhterated. 

Uterovesical  fistulae  are  usually  situated  in  the  anterior  lip  of 
the  cervix,  near  the  internal  os.  They  are  usually  on  the  left 
side  of  the  median  line  and  are  small  in  caliber. 

Enterovesical  fistulae  are  exceedingly  rare.  Fritsch,^  in  his 
enormous  experience,  has  seen  but  a  single  case. 

1  Fritsch  operated  on  200  urinary  fistulae  in  ten  years  ("  Handbuch  der  Gyn.," 
vol.  ii,  p.  84). 


OPERATIONS   ON   THE    VAGINA. 


879 


Colovesical  fistulse  are  more  common.  They  are  usually  the 
result  of  a  pelvic  abscess  which  opens  both  into  the  bowel  and 
into  the  bladder. 

Ureteral  fistulae  more  frequently  follow  gynecologic  operations 
than  labor.  They  are  naturally  small  in  size  and  are  usually 
situated  in  the  vaginal  vault,  though  they  may  empty  into  the 
uterus. 

Diagnosis. — It  is  usually  easy  to  recognize  a  vesicovaginal 
fistula.     There  is  incontinence  of  urine,  and  the  orifice  in  the 


Fit 


707. — Figure-of-eight   sutures  to  bring  together  the  lateral  fascial  jilates  under 
the  anterior  vaginal  wall. 


vesicovaginal  septum  is  \-isiblc  Ijy  the  aid  of  a  Sims  speculum. 
If  the  fistula  is  small,  a  uterine  sound  introduced  in  the  bladder 
may  be  made  to  emerge  from  the  orifice  in  the  vagina,  or  the 
sound  being  held  in  the  bladder,  a  surgeon's  ])robe  may  be  in- 
serted into  every  suspicious-looking  depresion  in  the  anterior 
vaginal  wall  until  the  communication  is  discovered  and  the  two 
instruments  grate  on  one  another.  Colored  fluid  (a  weak  per- 
manganate solution,  methylene-blue,  or  sterilized  milk)  may  be  in- 


880 


OBSTETRIC   OPERATIONS. 


jected  in  the  bladder  and  will  be  seen  oozing  out  of  a  small  open- 
ing on  the  anterior  vaginal  wall. 

A  cervical  fistula  may  be  detected  on  inspection:  separating 
the  lips  of  the  cervix,  the  tip  of  an  intravesical  sound  is  projected 
into  the  cervical  canal;  or,  injecting  the  bladder  with  colored 
fluid,  it  flows  out  of  the  cervix,  which  is  exposed  by  a  bivalve 
vaginal  speculum. 

A  ureteral  fistula  may  be  recognized  by  the  fact  that  part  of 
the  urine  is  voided  naturally,  wdiile  part  constantly  dribbles  away; 


Fig.  708. — Lateral  fascial  plates  united  and  redundant  vaginal  wall  excised. 


by  sounding  with  a  metal  ureteral  catheter  every  little  indenta- 
tion in  the  vaginal  vault  or  cervical  canal  until  the  ureter  is  cathe- 
terized  and  the  urine  flows  from  the  lower  end  of  the  catheter  drop 
by  drop  or  by  injecting  methylene-blue  hypodermatically,  draining 
the  bladder  with  a  rubber  tube,  and  packing  the  vagina  tightly 
with  gauze.  If  there  is  a  ureteral  fistula  the  deepest  portion  of 
the  packing  will  be  most  intensely  stained. 

An  enterovesical  or  a  colovesical  fistula  is  recognized  by  a 


OPERATIONS   ON   THE    VAGINA.  88 1 

microscopic  examination  of  the  urine,  which  shows  food  par- 
ticles and  feces.  "A  fecal  odor  to  tlie  urine  is  not  always  pres- 
ent and  does  not  always  denote  a  communication  with  the  bowel" 
(Fritsch).  An  ingenious  method  of  diagnosticating  these  fistulae 
was  demonstrated  by  Noble  after  Senn  had  discovered  the  hy- 
drogen gas  test  for  fecal  fistulae.  A  catheter  was  inserted  in  the 
urethra,  the  bowel  was  inflated  with  hydrogen,  and  the  gas  was 
ignited  as  it  escaped  from  the  end  of  the  catheter. 


Fig.  709. — Vaginal  walls  united  with  interrupted  sutures. 

Treatment. — There  is  always  a  chance  of  a  vesicovaginal  fistula 
healing  spontaneously.  There  are  three  methods  by  which  a 
spontaneous  cure  is  effected:  First,  by  granulation  tissue  filling 
the  opening  and  eventually  closing  it.  This  result  is  favored  by 
irrigation  of  the  vagina  to  keep  it  clean,  by  draining  the  l:)]adder 
after  the  fifth  day  postpartum  witli  a  catheter  or  rubber  tube,  and 
by  touching  the  edges  of  the  fistula  with  a  little  nitric  acid  to  promote 
exuberant  granulation,  although  the  application  of  the  caustic  had 
better  be  omitted  if  the  case  is  apparently  i)ursuing  a  favorable 
56 


882 


OBSTETRIC   OPERATIONS. 


Fig.  710. — Fistulse  of  the  genital  organs:  a,  Vesico-uterine  fistula;  b,  vesico- 
cervical fistula  ;  c,  vesicovaginal  fistula ;  d,  urethrovaginal  fistula ;  e,  rectovaginal 
fistula ;  y,  perineovaginal  fistula  (Beigel). 


Fig.  711. — Vesicovaginal  fistula. 


OPERATIONS   ON   THE    VAGINA. 


883 


course.  Second,  by  an  inflammatory  infiltration  and  swelling 
of  the  vaginal  walls,  which  approximate  the  edges  of  the  fistula 
and  keep  them  close  together  until  union  is  secured.  Third,  by 
cicatrization,  which  in  the  course  of  three  months  may  close  an 
opening  as  large  as  a  silver  dollar. 

The  operative  treatment  should  be  postponed  until  at  least  a 
month  after  labor,  to  allow  for  the  chance  of  spontaneous  closure, 
to  obtain  firmer  tissue  for  the  plastic  surgery,  and  to 
secure  contraction  of  the  fistula.  \  j) 

The  vagina,  bladder,  and  ^•ulva  should  be  ren- 
dered as  healthy  as  possible  by  sitz-baths  and  irriga- 
tions with  boracic  acid  and  weak  permanganate 
solutions.  If  the  fistula  is  caused  by  a  foreign  body, 
such  as  an  embedded  pessary  or  a  stone,  sufficient 
time  must  be  allowed  after  its  removal  to  secure  a 
complete  healing  over  of  ulcerated  surfaces  and  a 
cessation  of  purulent  discharge. 

General  anesthesia  is  usually  required.  Local 
anesthesia  is  not  to  be  recommended. 

The  dorsal  position,  with  raised  buttocks  and 
limbs  fixed  in  leg-holders  and  stirrups,  is  most  suit- 
able for  the  majority  of  cases.  In  fistulae  deep  within 
the  genital  canal,  Sims's  position  or  the  knee-chest 
posture  may  be  necessary.  For  the  latter  a  specially 
constructed  wedge-shaped  cushion  is  the  most  con- 
venient and  safest  support.  Sims's  specula  with 
blades  of  varying  length  and  breadth  and  lateral  vag- 
inal retractors  ;  scissors,  curved  on  the  flat,  sharp 
pointed,  with  thin  blades;  knives  set  at  an  angle  on 
the  shaft,  as  well  as  an  ordinary  narrow-bladed  scalpel; 
bullet-forceps;  two  Ulrich  tenacula  and  single  tenacula; 
a  rat-toothed  tissue  forceps;  a  needle-holder  and  as- 
sorted needles,  most  of  which  should  be  full  curved, 
round -pointed,  and  delicate,  and  some  of  which  should 
have  the  fish-hook  curve,  are  the  instruments  required. 
The  suture  material  should  be  silkworm  gut,  formalin  catgut,  and 
fine  silk.  The  last  is  recommended  most  highly  by  Fritsch,  whose 
experience  with  these  ojjerations  is  greater  than  that  of  any  other 
surgeon.  The  field  of  operation  is  exposed  by  pulling  down  the 
cervix  with  a  strong  silk  ligature,  transfixing  its  lips  at  a  sufficient 
height  above  the  external  os  to  j)revent  the  ligature  cutting  out 
(i  centimeter),  by  \aginal  retractors  or  by  fixing  the  lal)ia  with 
bullet-forceps  and  pulling  them  apart.  It  is  occasionally  necessary 
to  dilate  the  vaginal  canal  narrowed  by  cicatrization,  and  to  cut, 
stretch,  or  tear  cicatricial  bands  obstructing  access  to  the  fistula. 


Fig.  712.— 

Ulrich"  s    ten- 
aculum. 


884 


OBSTETRIC   OPERATIONS. 


The  shape  and  extent  of  the  denudation  are  governed  by  the  situa- 
tion and  extent  of  the  fistula.  The  length  of  the  wound  should, 
if  possible,  run  across  the  vagina,  as  the  vaginal  walls  are  more 
easily  approximated  from  above  downward  than  transversely. 
For  small  fistulae  a  long  linear  incision  having  the  fistula  as  its 
midpoint,  with  a  broad  denuded  surface  secured  by  a  flap-splitting 
dissection,  is  the  best.  For  larger  fistulae  the  denudation  repre- 
sented in  Figs.  714  and  715  is  preferable.  The  breadth  of  the 
denudation  should  never  be  less  than  i  to  2  centimeters.  If  one 
edge  of  the  fistula  is  adherent  to  the  pubis  or  so  fixed  by  cicatrices 
that  it  is  immobile,  a  thick  flap  may  be  prepared  from  the  vaginal 


Fig.  713. — Denudation  for  a  small 
fistula  (Fritsch). 


Fig.  714. — Denudation  for  fistula  with  ten- 
sion on  the  edges  of  the  wound  (Fritsch). 


Fig-  715- — Insertion  of  the  suture  after  the  denudation  :  a,  a,  Suture  just  above  the 
vesical  mucosa;   b,  b,  suture  emerging  in  the  vagina  (Fritsch). 

wall  with  a  broad  base,  with  the  least  torsion  of  the  pedicle  possible, 
and  larger  in  all  its  dimensions  than  the  denuded  surface  it  is  de- 
signed to  cover.  The  flap  is  fixed  by  buried  sutures  of  fine  catgut, 
the  edges  of  the  mucous  membrane  being  united  by  superficial 
stitches  of  silk  or  silkworm  gut.  A  flap  may  be  prepared  by  a 
semicircular  incision  with  its  base  alonside  the  fistula;  it  is  turned 
on  its  base  so  that  the  vaginal  mucous  surface  projects  into  the 
bladder;  after  the  edges  are  fixed  by  fine  catgut  in  the  denuded 
edges  of  the  fistula,  the  raw  surface  is  covered  by  the  approxima- 
tion of  the  vaginal  mucous  membrane  surrounding  it  (Martin). 

Ferguson  proposes  a  circular  incision  around  the  fistula  3 
to  6  mm.  from  its  margin,  do\A-n  to  the  vesical  wall.  The  vagi- 
nal flap  is  dissected  loose,  turned  inward,  and  its  free  edges  united 


OPERATIONS   ON   THE    VAGINA.  885 

with  fine  formalin  gut,  thus  closing  the  fistula.  The  raw  surfaces 
left  in  the  vagina  are  approximated  by  interrupted  sutures. 

It  may  be  impracticable  to  close  a  large,  irregularly  shaped 
fistula  at  one  sitting.  The  most  easily  approximated  edges  are 
united  at  one  operation  and  the  remainder  of  the  opening  is 
closed  subsequently. 

The  anterior  lip  of  the  cervix  may  be  used  as  a  plug  to  cover 
in  a  considerable  defect  in  the  bladder  wall.  The  author  has 
thus  closed  a  fistula  admitting  four  fingers,  due  to  the  ulceration 
of  a  neglected  pessary  through  the  vesicovaginal  septum.  The 
lateral  extremities  of  the  fistula  were  closed  in  the  ordinary  way 
and  the  denuded  vaginal  portion  of  the  cervix  was  fastened  in 
the  center  of  the  wound,  where  a  defect  existed  too  extensive  to 
be  covered  by  vaginal  flaps. 

In  closing  fistulae  extending  a  consid- 
erable distance  transversely,  care  must 
be  exercised  to  locate  the  ureteral  orifices, 
which  otherwise  might  be  buried  in  the 
denuded  surface  or  occluded  by  a  suture. 

In  suturing  a  denuded  area  around  or 
a  transplanted  flap  over  a  vesical  fistula, 
the  needle  must  not  penetrate  the  vesical  /'    \ 

mucous  membrane.      If  it  does,  an  in-        tt     „,a     a       ■.•       1 

'  Jbig.  710. — Apposition  when 

travesical  hemorrhage  will  probably  re-  the  denudation  is  properly  made 
suit    in  a  failure  of  the    operation    or  the       and  the  suture  correctly  inserted 

suture  tract  may  develop  into  another     ^  "  ^'^  '' 
fistula.    Acquired  atresia  of  the  vagina  is 

a  method  of  spontaneous  cure  not  infrequently  seen.  If  the  patient 
has  passed  the  menopause,  she  remains  comfortable;  but  if  she  men- 
struates into  the  bladder,  there  may  be  severe  distress  at  the  periods/ 
and  if  the  lower  portion  only  of  the  vaginal  canal  is  closed,  a  sac 
exists  beneath  the  level  of  the  fistula  in  which  blood,  pus,  and  de- 
composed urine  collect.  It  is  occasionally  impossible  to  close  a 
serious  defect  in  the  posterior  wall  and  base  of  the  bladder.  In 
such  cases  a  colpocleisis  is  justifiable,  if  the  precaution  is  taken  to 
close  the  canal  up  to  the  level  of  the  fistula,  leaving  no  vaginal  sac 
below  for  the  retention  of  decomposed  urine  and  menstrual  dis- 
charge. 

Fritsch  has  closed  a  fistula  by  denuding  the  anterior  surface 
of  the  posterior  lip  of  the  cervix  in  a  case  of  defect  of  the  ante- 
rior lip  and  implanting  the  posterior  lip  in  the  vesical  opening. 

1  In  a  case  of  vesicovaginal  fistula,  acquired  atresia  of  the  vagina,  a  retroflexed 
and  fixed  uterus  with  saljiin^o-oophoritis,  menorrhagia  and  severe  dysmenorrhea,  due 
to  the  passage  of  clots  from  the  urethra,  the  author  has  been  obliged  to  perform 
hysterectomy. 


886 


OBSTETRIC   OPERATIONS. 


The  woman  menstruated  into  the  bladder,  but  nevertheless  re- 
mained comfortable  for  years. 

To  close  the  vagina  (colpocleisis),  a  circular  denudation  is  made 
around  the  whole  canal  2  centimeters  broad,  at  a  sufficient  height 
to  preclude  the  formation  of  a  sac  below  the  level  of  the  fistula; 
a  row  of  interrupted  sutures  across  the  vagina,  inserted  from  before 
backward,  closes  the  canal.  In  difficult  cases  of  extensive  fistulge 
deep  within  the  vagina,  and  of  fixation  of  the  bladder  by  cicatricial 
adhesions,  the  following  procedures  have  been  advocated  and 
adopted : 

Incision  into  the  anterior  bladder-wall  by  suprapubic  cystot- 
omy in  the  Trendelenburg  posture  and  closure  of  the  fistula  from 


Fig.  717. 


-Flap-formation  as  suggested 
by  Ferguson. 


Fig.  71S. — Flap  turned  in  and  vesical 
opening  closed. 


above,  silk  ligatures,  if  they  are  used,  being  left  long  and  led  out 
of  the  urethra,  whence  they  are  removed  by  traction  after  they 
have  cut  through  the  tissue;  or  buried  catgut  sutures  may  be 
employed  (Trendelenburg). 

A  transverse  incision  over  the  pubis,  freeing  the  bladder,  and 
closure  of  the  fistula  from  the  vagina  (Fritsch). 

Separation  of  the  vagina  from  the  bladder  around  the  fistula, 
closure  of  the  opening  in  the  bladder,  and  a  separate  closure  of 
the  vaginal  wound,  as  in  anterior  colporrhaphy  (\\^internitz, 
Mackenrodt). 

Opening   Douglas's  pouch,   retroverting   the   uterus  into   the 


OPERATIONS    ON   THE    VAGINA. 


887 


vagina,  using  its  posterior  surface  (which  becomes  anterior  in 
the  complete  retroversion)  as  a  plug  to  fill  in  a  large  defect  in  the 
vesicovaginal  septum,  and  making  an  artificial  os  in  the  fundus  to 
allow  the  escape  of  menstrual  discharge  (Freund). 

If  the  urethra  is  absent  or  partly  destroyed,  its  restoration  is 
always  doubtful.  The  most  hopeful  plan  is  to  prepare  a  flap  of 
mucous  membrane  as  thick  as  possible  from  one  side,  to  turn  it 
inward  so  as  to  bring  the  mucous  surface  within  the  newly  made 
canal,  and  to  fasten  it  in  a  denuded  area  on  the  opposite  side. 
The  new  urethra  should  be  established  before  the  vesical  fistula 
is  closed. 

Fortunately,  continence  may  be  established  without  the  pres- 
ence of  a  urethra  bv  leaving  a  narrow  orifice  at  the  neck  of  the 


Fig-    719. — The  vesical   opening   closed   and   sutures   inserted   to  unite   the  vaginal 

walls. 


bladder.  This  was  accomplished  in  one  of  the  author's  cases 
after  several  futile  attempts  to  construct  a  new  urethra,  which  was 
entirely  lacking,  directly  back  of  the  external  meatus. 

If  there  is  such  a  serious  defect  of  urethra  and  base  of  bladder 
that  no  plastic  operation  succeeds  in  restoring  even  partial  con- 
tinence, colpocleisis  and  a  rectovaginal  fistula  may  make  the 
];atient's  condition  endurable.  But  if  there  is  a  cystitis  at  the 
time  of  o])eration,  the  result  may  be  fatal  from  an  exacerbation 
of  the  inflammation  and  infection  of  the  ureters  and  kidneys. 
Indeed,  there  is  always  danger  after  such  an  operation  of  pyelo- 


OBSTETRIC   OPERATIONS. 

nephritis,  though  occasionally,  as  in  one  of  Fritsch's  cases,  the 
patient  remained  comfortable  and  well  for  years. 

The  rectovaginal  fistula,  admitting  a  forefinger,  should  be 
made  by  a  transverse  incision  just  above  the  sphincter  ani,  the 
vaginal  and  rectal  mucous  membranes  being  united  by  interrupted 
sutures  of  catgut.  The  vaginal  orifice  is  then  closed.  .  A  double 
rubber  drainage-tube  is  inserted  through  the  fistula,  and  during 
the  patient's  convalescence  the  vesicovaginal  pouch  is  frequently 
irrigated  with  a  boracic  acid  solution. 

The  most  important  question  to  decide  in  the  a]ter -treatment 
of  a  vesicovaginal  fistula  operation  is  whether  to  resort  to  drainage 
of  the  bladder  or  to  catheterization.  After  trying  both  plans,  I 
prefer  the  mushroom  retention  catheter  for  four  days.  After  the 
operation  the  bladder  is  injected  with  water  to  test  its  imperme- 
ability. The  vagina  is  lightly  packed  with  iodoform  gauze.  The 
stitches  of  fine  Pagenstecher  thread  are  removed  in  a  week. 

If  a  ureter  has  been  included  in  one  of  the  stitches,  there  are 
the  symptoms  of  deficient  urinary  secretion,  rapid  pulse,  pain  in 
the  back,  a  tendency  to  somnolence,  and  sometimes,  though 
rarely,  high  fever.  There  are  two  courses  open  to  the  operator: 
one  is  to  remove  the  stitches  and  to  do  the  operation  over  again; 
the  other  is  to  trust  to  nature  to  overcome  the  difficulty,  which  is 
often  done  by  the  stitch  cuttiDg  through,  by  the  urine  under  pres- 
sure forcing  its  way  through  the  loop  of  the  ligature,  or  by  the  estab- 
lishment of  a  ureterovaginal  fistula.  Occasionally  the  kidney  on 
the  affected  side  atrophies  and  the  remaining  kidney  performs  the 
work  of  two,  as  after  a  nephrectomy. 

If  there  is  a  persistence  of  incontinence  after  the  operation, 
the  flow  of  urine  may  come  from  a  suture  track,  from  a  failure 
of  union  at  some  part  of  the  wound,  or  from  a  second  fistula  not 
detected  at  the  time  of  the  operation.  The  last  two  conditions 
require  subsequent  operations.  A  small  suture-track  fistula  often 
closes  spontaneously,  and  some  time  should  be  allowed  for  this 
result  before  subjecting  the  patient  to  a  second  operation,  which 
might  be  unnecessary. 

Intravesical  hemorrhage  will  not  occur  after  an  operation 
for  vesicovaginal  fistula  if  the  sutures  are  properly  placed.  If  it 
does,  it  is  an  awkward  compHcation.  The  bladder  should  be 
washed  out  with  boracic  acid  solution  every  two  hours  to  prevent 
the  formation  of  a  large  clot.  If  a  clot  does  form  in  the  bladder, 
causing  tenesmus,  the  injection  of  pepsin  solution  has  been  rec- 
ommended to  soften  it. 

The  Treatment  of  Ureteral  Fistulae  and  of  Surgical  Injuries  of  the 
Ureters. — There  are  three  kinds  of  surgical  treatment  for  ureteral 
fistulae:  nephrectomy,   a  plastic  operation  in  the  vagina   {colpo- 


OPERATIONS   ON   THE    VAGINA.  889 

uretero-cystostomy  or  ureteral  anastomosis)  and  an  abdominal  sec- 
tion, followed  by  the  junction  of  the  ureter  (celio-uretero-ureteros- 
tomy)  or  its  implantation  in  the  bladder  {celio-uretero-cystostomy). 

A  nephrectomy  is  often  the  easiest  way  to  remove  the  dis- 
agreeable symptoms  of  a  ureteral  fistula,  but  it  is  not  the  ideal 
operation.  There  must  always  be  some  doubt  as  to  the  ade- 
quacy of  the  remaining  kidney,  and  the  natural  impulse  is  to 
avoid  the  removal  of  such  an  important  organ  unless  it  is  itself 
diseased.  It  must  be  admitted,  however,  that  the  operation  has 
been  repeatedly  performed  with  success.  Several  of  the  women  ^ 
have  subsequently  been  delivered  at  term  without  the  slightest 
disturbance  of  health.  As  in  nephrectomies  for  any  indication, 
the  most  scrupulously  careful  examination  should  be  made  of  the 
secretion  from  the  remaining  kidney  by  catheterizing  the  ureter 
or  by  vesical  segregators  (Harris's,  Cathelin's,  or  Luys's).  If  the 
kidney  corresponding  to  the  ureteral  fistula  shows  evidence  of 
pyelonephritis  or  hydronephrosis,  there  is  additional  justification 
for  its  removal,  but  it  should  be  remembered  that  both  of  these 
conditions  have  disappeared  after  closure  of  the  fistula  by  vaginal 
or  abdominal  operations. 

Nephrectomy  should,  in  general,  be  limited  to  those  cases  in 
which  the  closure  of  the  fistula  has  proved  impracticable  by  both 
the  vaginal  and  abdominal  routes  or  in  which  there  is  marked 
hydronephrosis  or  pyelitis. 

The  operation  may  be  performed  by  a  lumbar  incision  or  by 
the  transperitoneal  method.  The  latter  is  often  easier  for  the 
surgeon,  but  may  not  be  so  safe  for  the  patient.  There  is  no 
necessity  for  the  exsection  of  the  ureter,  and  there  need  be  no 
fear  of  the  regurgitation  of  urine  from  its  lower  segment.  If  the 
transperitoneal  operation  is  selected,  the  incision  should  be  made 
laterally  through  the  abdominal  wall  directly  over  the  kidney. 
The  posterior  parietal  layer  of  the  peritoneum  is  opened,  the 
kidney  delivered,  and  its  pedicle  (blood-vessels  and  ureter)  is  tied 
with  silk  or  catgut  by  passing  a  pedicle  needle  through  its  middle, 
tying  in  both  directions,  and  then  back  again  around  the  whole 
stump.  This  step  in  the  operation  is  usually  easier  in  the  trans- 
peritoneal than  in  the  lumbar  operation.  Both  layers  of  peri- 
toneum are  closed. 

In  the  lumbar  operation  the  kidney  is  delivered  and  the  ves- 
sels, with  the  ureter,  ligated. 

The  lumbar  incision  should  always  be  preferred  if  there  is 
pyelonephritis  or  perinephritis,  or  if  the  most  perfect  aseptic 
technic  is  impracticable.  Many  operators  accustomed  to  neph- 
rorrhaphy  by  this  method  prefer  it  uniformly. 

iFritsch  reports  three  cases  (^loc  ciL). 


890  OBSTETRIC   OPERATIONS. 

The  Vaginal  Operations  for  Ureteral  Fistula. — The  first  requi- 
site for  a  successful  plastic  operation  by  the  vagina  is  to  find  the 
upper  end  of  the  ureter  and  its  orifice,  which  is  not  always  easy 
to  do.  If  there  is  not  too  much  scar-tissue  the  ureter  may  be 
dissected  out,  implanted  into  an  incision  made  into  the  bladder, 
and  fastened  in  place  by  several  interrupted  sutures  of  fine  catgut. 
The  vaginal  wound  is  closed  over  the  end  of  the  ureter  and  the 
opening  in  the  bladder  into  which  it  has  been  implanted  (Parvin, 
Mc Arthur).  It  has  sometimes  been  possible  to  sew  the  mucous 
membrane  of  the  bladder  to  the  m^ucous  membrane  of  the  ureter 
and  so  to  fasten  the  latter  in  place.  The  vaginal  mucous  mem- 
brane, dissected  back  on  each  side  by  a  flap-splitting  dissection, 
is  united  over  the  ureter  and  the  newly  made  opening  into  the 
bladder. 

Schede's  operation  has  given,  on  the  whole,  the  best  results:  a 
vesicovaginal  fistula  is  made  close  by  the  ureteral  fistula,  the 
mucous  membrane  of  the  bladder  and  that  of  the  vagina  being 
united  by  interrupted  sutures  of  catgut;  an  oval  denudation  is 
made  i  centimeter  wide  around  both  the  ureteral  and  the  vesical 
fistula,  leaving  a  strip  of  undenuded  membrane  0.5  centimeter 
wide  immediately  surrounding  both  fistulse.  The  denuded  sur- 
faces are  united  by  interrupted  sutures,  thus  directing  the  stream 
of  urine  from  the  ureter  into  the  bladder. 

BandVs  operation  is'  only  practicable  if  both  ends  of  the  ureter 
are  discoverable  and  are  normally  patent.  A  ureteral  catheter  is 
passed  into  both  the  lower  and  the  upper  segments  of  the  ureter, 
emerging  from  the  urethra.  A  denudation  is  made  and  united 
as  in  Schede's  operation,  but  without  making  a  vesicovaginal  fis- 
tula. If  the  catheter  is  fenestrated  the  whole  bladder  is  drained  by 
it,  or  the  urethra  may  be  drained  by  a  rubber  tube  through  which 
the  ureteral  catheter  passes. 

Mackenrodfs  operation  is  very  ingenious  and  has  been  suc- 
cessful in  the  few  cases  in  which  it  was  tried.  A  vesicovaginal 
fistula  is  made  near  the  ureteral  fistula.  A  semicircular  thick 
flap  of  vaginal  mucosa  is  dissected  off,  so  that  it  carries  the  ureteral 
opening  in  its  center,  has  its  attached  base  next  to  the  vesico- 
vaginal fistula,  and  its  free  edge  away  from  it.  By  turning  this 
flap  over  a  half  circle  on  its  base  it  closes  the  vesicovaginal  fistula 
like  a  lid;  it  is  sewed  in  place  by  catgut  sutures,  with  the  vaginal 
mucous  membrane  directed  into  the  bladder,  and  so  turning  the 
ureteral  fistula  into  the  bladder.  The  raw  surfaces  left  by  the 
removal  of  the  flap  and  over  the  vesicovaginal  fistula  are  united 
with  interrupted  sutures  or  are  allowed  to  granulate. 

Dudley's  operation,  as  Reynolds^  says,  is  a  crude  procedure, 

1  "  Boston  Med.  and  Surg.  Jour.,"  1901,  p.  84. 


OPERATIONS   ON   THE    VAGINA.  89 1 

but  has  succeeded  when  other  plans  have  failed.  A  sharp-pointed 
artery  or  other  similar  forceps  is  passed  into  the  urethra;  a  vesi- 
covaginal opening  is  made;  one  blade  of  the  forceps,  which  is 
opened  for  the  purpose,  is  pushed  out  of  the  incision  in  the  bladder; 
the  renal  end  of  the  ureter  is  threaded  on  it;  the  handles  of  the 
instrument  are  closed  and  tied,  thus  clamping  the  end  of  the  ureter 
to  the  bladder  wall.  The  forceps  is  lightly  jjulled  upon  after 
eight  or  ten  days.  If  it  does  not  come  away  it  is  opened  and 
extracted. 

The  Abdominal  Operation  for  Ureteral  Fistula  or  Injury. — If 
the  ureter  is  injured  during  an  operation,  it  may  be  repaired  in 
several  ways:  If  the  incision  is  linear  or  fails  to  sever  the  ureter 
completely,  the  wound  may  be  repaired  by  fine  catgut  sutures, 
mattress  or  interrupted,  with  considerable  certainty  of  success. 
If  the  ureter  is  completely  severed,  is  fenestrated  or  badly  crushed, 
as  by  clamp  forceps,  it  may  be  rejoined  by  an  end-to-end  anas- 
tomosis (Tauffer,  Bovee),  by  an  end-to-end  (Pozzi)  or  a  lateral 
invagination  (Van  Hook's  uretero-ureterostomy),  or  by  a  lateral 
anastomosis.  In  the  first,  a  section  of  a  ureteral  catheter  is  passed 
into  both  segments  of  the  ureter,  with  a  silk  ligature  tied  around 
its  middle  to  recover  it  by  if  it  should  slip  down  the  lower  portion 
of  the  canal.  Interrupted  sutures  of  fine  silk  or  formalin  catgut 
are  passed  through  walls  of  the  two  ends  of  the  ureter;  before  the 
knots  are  tied  the  catheter  is  withdrawn.  The  author  has  had  one 
successful  end-to-end  anastomosis. 

Van  Hook's  lateral  invagination  is  the  most  reliable  opera- 
tion. The  upper  end  of  the  lower  segment  of  the  ureter  is  ligated; 
a  linear  incision  is  made  through  its  wall  below  the  ligature  twice 
as  long  as  the  diameter  of  the  ureter;  the  upper  segment  is  im- 
planted into  this  incision  and  is  fastened  by  fine  sutures  at  both 
ends  of  the  wound;  the  edges  of  the  incision  are  then  carefully 
sewed  to  the  ureteral  wall  passing  between  them,  so  that  the  open- 
ing is  securely  closed.  If  a  junction  of  the  two  ends  of  a  severed 
ureter  is  impossible,  as  in  a  case  of  old  injury,  extensive  destruction 
of  tissue  or  the  removal  of  a  considerable  jjortion  of  the  ureter  in  the 
wall  of  a  cyst  or  a  fibroid  tumor,  implantation  of  the  upper  segment 
into  the  bladder  (celio-uretero-cystostomy)  is  indicated.  This  may 
be  done  by  a  transperitoneal  or  an  extraperitoneal  operation.  In 
the  former  the  peritoneum  over  the  ureter  is  incised,  usuallv  in  the 
neighborhood  of  the  bifurcation  of  the  iliac  arteries;  the  ureter  is 
dissected  free,  care  being  taken  not  to  isolate  it  too  extensively,  on 
account  of  danger  to  its  nutrition.  An  incision  is  made  into  anv 
portion  of  the  bladder-wall  wjiich  the  ureter  reaches  without  ten- 
sion; the  end  of  the  ureter  is  inserted  into  the  opening  so  that  it 
projects  somewhat  into  the  bladder;  the  wJges  of  the  wound  in  the 


892  OBSTETRIC    OPERATIONS. 

latter  are  carefully  sewed  to  the  wall  of  the  ureter  by  interrupted  or 
mattress  sutures,  and  its  angles  are  closed  by  separate  sutures. 
Penrose  recommends  splitting  the  end  of  the  ureter,  putting  a 
mattress  suture  in  each  lip,  and  passing  each  end  of  the  mattress 
sutures,  rethreaded  on  a  fine  needle,  through  the  bladder-wall, 
tying  them  on  the  peritoneal  surface  of  the  bladder.  This  plan 
avoids  occlusion  of  the  ureteral  orifice  and  prevents  the  ureter  slip- 
ping out  of  the  bladder. 

There  are  disadvantages  in  the  transperitoneal  operation. 
Failure  may  mean  fatal  peritonitis  in  spite  of  drainage;  and  the 
band  of  isolated  ureter  traversing  the  pelvic  and  lower  abdominal 
cavities  may  cause  intestinal  complications. 

The  extraperitoneal  operation  is  the  ideal  one  if  it  is  prac- 
ticable. The  implantation  of  the  ureter  in  the  bladder  by  a  vagi- 
nal operation  has  been  described  (p.  890).  In  an  abdominal 
operation  it  may  be  possible  to  reach  the  upper  segment  by  in- 
cising the  anterior  layer  of  the  broad  ligament  and  the  vesico- 
uterine pouch,  and  to  implant  the  ureter  under  the  peritoneal 
covering  of  the  latter. 

Witzel  proposes  to  free  the  ureter  as  in  the  transperitoneal 
operation,  carrying  its  end  by  forceps  around  the  brim  of  the 
pelvis  under  the  peritoneum,  and  bringing  it  forward  above  the 
anterior  parietal  peritoneum.  Both  incisions  in  the  peritoneum 
iare  closed  and  the  operation  is  concluded  extraperitoneally  by 
implantation  of  the  ureter  in  the  bladder,  the  ureter  being  cut 
obliquely,  so  that  its  end  is  a  point,  the  bladder  being  incised 
obliquely,  so  that  the  implanted  ureter  runs  some  distance  in  its 
wall.  It  is  necessary  to  fasten  the  bladder  wall  to  the  pelvic  con- 
nective tissue  by  catgut  sutures  to  avoid  tension  on  the  implanted 
ureter.  Mackenrodt  modifies  this  procedure  by  making  his  ab- 
dominal incision  at  the  outer  edge  of  a  rectus  muscle;  separating 
the  peritoneum  to  the  bifurcation  of  the  iliac  artery,  bringing  the 
end  of  the  ureter  forward  above  the  peritoneum,  puncturing  the 
bladder  from  within  by  a  trocar,  and  drawing  the  end  of  the 
ureter  into  it.  If  the  ureter  is  so  much  shortened  that  its  upper 
portion  cannot  be  made  to  reach  the  bladder  without  too  much 
tension,  the  following  ingenious  plans  have  been  proposed  to 
splice  it:  The  two  ends  of  the  ureter  are  brought  out  on  the 
abdominal  skin  and  fastened  there;  after  the  wound  has  healed, 
a  tube  of  skin  is  made  between  the  two  ureteral  orifices  by  par- 
allel incisions,  and  uniting  the  free  edges  of  the  skin ;  the  tube  is 
depressed  and  covered  over  by  uniting  the  outer  edges  of  the 
parallel  incisions  (Rydygier).  A  diverticulum  is  constructed  from 
the  anterior  bladder  wall,  into  which  the  upper  end  of  the  ureter 
is  implanted  (Van  Hook,  Boari,  Casati).     The  ureter  is  spHced 


OPERATIONS   ON  THE    VAGINA.  893 

by  a  hollow,  decalcified  turkey's-wing  bone  sewed  in  the  ureter 
and  the  bladder  (Van  Hook).  The  ureter  is  spliced  by  a  seg- 
ment of  small  intestine,  separated  from  the  bowel  which  is  joined, 
by  an  end-to-end  anastomosis;  the  segment  of  gut  is  left  attached 
to  its  mesentery  and  is  closed  by  sutures  at  both  ends.  The  two 
ends  of  the  ureter  are  implanted  in  the  segment  of  bowel  (Bacon). 
The  appendix  is  used  to  spHce  the  ureter  (Giannettasio).  The 
ureter  is  implanted  in  the  Fallopian  tube  (D'Urso  and  Fabii). 
These  propositions  have  been  theoretical  or  else  the  result  of 
experiments  on  dogs.^ 

As  in  all  intra-abdominal  operations  on  the  ureters  and  blad- 
der, the  Trendelenburg  posture  is  essential,  and  gauze  drainage 
afterward  is  necessary  in  case  the  closure  of  the  bladder  or  junc- 
tion of  the  ureters  proves  imperfect. 

Bovee ^  collected  iii  uretero-cystostomies  to  1903. 

Operations  for  Acquired  Stenosis  or  Atresia  of  the  Vagina. 
— The  treatment  of  stenosis  of  the  vagina  has  for  its  object  the  dilata- 
tion of  the  canal.  This  is  accomplished  in  various  ways.  Gradual 
dilatation  with  bougies  may  suffice;  but  the  treatment  must  be  con- 
tinued persistently  a  long  time  and  may  not  lead  to  a  permanent 
cure.  Fibromyxomatous  bands  and  membranes  stretched  across 
the  vagina  should  be  excised.  Usually  there  is  no  occasion  for 
hemostasis,  but  it  is  advisable  to  draw  the  mucous  membrane 
over  the  wounded  surfaces  by  interrupted  sutures  of  catgut. 
Cicatricial  bands  under  the  mucous  membrane  should  be  incised 
as  deeply  as  possible  wherever  they  are  felt  to  be  most  tense. 
They  may  be  torn  by  the  finger  even  more  deeply  than  they  can 
safely  be  cut.  The  mucous  membrane  alone  is  united  over  the 
wounds  with  interrupted  sutures  introduced  in  a  direction  parallel 
with  the  cut,  so  as  to  further  enlarge  and  not  to  contract  the 
vagina.  A  vaginal  plug  (Sims')  of  glass,  hard  rubber,  or  metal 
should  then  Idc  inserted,  and  should  be  retained  continuously 
for  a  month,  being  removed  daily  to  be  cleansed  and  to  allow 
irrigation  of  the  vagina.  The  plug  should  be  worn  for  a  few 
hours  daily  during  the  year  succeeding  the  operation,  iDcing  re- 
tained by  a  napkin  or  by  special  apparatus  which  the  author  lias 
employed  with  satisfaction  (Fig.  720). 

If  the  stenosis  exceeds  the  whole  length  of  tlic  \'agina  and  is 
extreme  in  degree,  the  success  of  any  treatment  is  ])roblematical. 
If  the  patient  comes  under  the  physician's  ol)servalion  when  she 
is  pregnant,  a  Porro  Cesarean  section  is  required  al  term.     After 

'  Henry  Morris,  "Surgical  Diseases  of  the  Kidney  and  UrettT,"  vol.  ii,  p.  608, 
and  Nicholson,  "Treatment  of  Severed  Ureters,"  "  Amer.  Jour.  Med.  Sci.,"  April, 
1902. 

"^  "Am.  (jyn.,"  July,  1903. 


894 


OBS  TE  TRIG   OPERA  TIONS. 


the  removal  of  the  uterus  the  stenosis  of  the  vagina  requires  no 
treatment. 

The  treatment  of  atresia  has  for  its  object  the  restoration  of 
the  caliber  of  the  vagina  and  the  restitution  of  an  external  outlet 
for  the  discharge  of  the  genital  tract.  The  same  principles  ob- 
tain in  the  treatment  of  congenital  and  acquired  atresia,  but  the 
latter  is  often  more  difficult  to  deal  with.  The  condition  of  the 
tubes  should  receive  the  first  attention.  If  there  is  hematosalpinx, 
the  tubal  sac  should  be  removed  by  an  abdominal  section  before 
the  vagina  is  opened  and  the  blood  in  the  uterus  and  vagina  is 
evacuated.     The  numerous  deaths  after  operations  for  atresia  have 


Fig.  720. — Silver  plug  (Sims')  supported  by  abdominal  belt  and  rubber  bands. 

been  due  to  tubal  infection  or  rupture  and  a  consequent  peri- 
tonitis. 

To  open  the  occluded  vaginal  canal  it  may  be  sufticient  to 
make  a  crucial  incision  in  a  membranous  septum  or  to  excise  it 
at  its  base.  The  retained  blood,  as  thick  sometimes  as  tar,  flows 
out  slowly  and  should  be  thoroughly  washed  away  by  a  boracic 
acid  solution.  The  wounded  surface  encircling  the  vagina,  if 
the  membrane  is  excised,  is  covered  with  mucous  membrane 
by  inserting  interrupted  sutures  from  above  downward,  uniting 
the  mucous  membranes  of  the  healthy  portions  of  the  vagina. 
If  the  atresia  involves  a  considerable  length  of  the  vagina,  a 
blunt  dissection  is  required  between  the  bladder  and  rectum,  with 
a  sound  in  one  and  the   forefinger  of  the  left  hand  or  a  bougie 


OPERATIONS   ON   THE    VAGINA. 


895 


in  the  other,  the  tissues  being  separated  by  the  blunt  end  of  a 
closed  scissors,  the  occasional  stroke  of  a  knife,  and  the  opera- 
tor's fingers.     When  the  accumulated  fluid  is  reached  and  evacu- 
ated,  the  opening   which  has  been  secured   by  a  blunt  dissec- 
tion should  be  enlarged  as  much  as  possible  by  graduated  bougies, 
the  fingers,  or  powerful  branched  dilators,  the  force  being  ap- 
plied laterally  so  as  to  avoid  injury  to  the  bladder  or  rectum. 
The  problem  is  how  to  prevent  a 
reclosure  of  the  canal.     This  has 
been  accomplished  in  se\' eral  ways : 
The  prolonged  retention  of  a  plug 
with  the  idea  that  the  cahber  of  the 
vagina  shall  be  maintained  while  a 
proliferation  and  extension  of  the 
vulvar  epithelium  finally  covers  the 
raw  surfaces  with  a  new  mucous 
membrane ;     the   implantation    of 
flaps  gained   by  cutting   loose  the 
labia  minora  except  at  their  bases, 
spHtting  them  longitudinally,  join- 
ing them  together,  suturing  their 
edges,  and  inverting  them  into  the 
vagina,  where  they  are  sewed  fast 
(Kiistner);    implanting    a  tube  of 
vaginal    mucous     membrane    ob- 
tained from  a  prolapsed  vagina  in 
another  patient,  as  has  been  suc- 
cessfully done  by  INIackenrodt  and 
by  the  author  ;'^  implanting  intes- 
tinal  mucous   membrane   secured 
by  resection  of  the   bowel   in  an- 
other patient    {  '"  ^""-<-\:   making 
a  flap  anteriorl; 
eluding  the  vagina  anu  o.  i- 
flap  of  the  skin  on  the  labium  majuo,  . 
between  the  bladder  and  rectum  forming  a  cavity  u... 
flaps  are  sutured  (Fleming).     In  all  of  these  methods  some  plan 
must  be  adopted   to  keep   the  vagina  distended  and  the  trans- 
planted flaps  or  implanted  membrane  in  close  apposition  with  the 

1  In  the  author's  case  a  woman  with  total  prolapse  was  o]ierated  upon  first  ;  two 
broad  strips  of  mucous  mi'ml)ran(;  were  excised,  sewed  together  with  catgut  around  a 
cylindrical  speculum,  and  jilaced  in  a  warm  normal  salt  solution.  A  rapid  blunt  dis- 
section was  then  performed  on  the  patient  with  atresia  to  a  de]ith  of  3  inches.  The 
vaginal  mucous  membrane  on  the  speculum  was  imjilanted,  the  latter  withdrawn  after 
being  filled  with  iodoform  gauze,  which  remained  in  the  vagina  undisturbed  for  two 
weeks. 


Fig.  721. — Fleming's  operation 
for  making  an  artificial  vagina  :  i ,  An- 
terior flap;  2,  posterior  flap.  These 
flaps  are  turned  into  the  canal  made 
by  a  blunt  dissection  and  are  sutured 


896 


OBSTETRIC   OPERATIONS. 


raw  surfaces.  A  tampon  left  undisturbed  for  a  number  of  days 
and  a  vaginal  plug  have  been  employed  for  this  purpose,  but  there 
are  objections  to  both  plans.  Noble's  suggestion  to  insert  a  pouch 
of  thin  rubber  tissue  and  to  distend  it  with  gauze  packing  is  a 
good  one.  When  the  newly  made  vagina  is  clothed  with  mucous 
membrane  by  any  one  of  the  methods  just  described,  systematic 
attempts  to  retain  a  sufficient  cahber  in  the  canal  should  be  begun 
about  three  weeks  after  the  operation,  either  by  regular  daily  dila- 
tation with  a  bougie  or  by  the  use  of  the  vaginal  plug,  worn  daily 
for  at  least  an  hour.  Occasionally  the  most  satisfactory  operation 
for  atresia  is  hysterectomy.     In  a  case  under  the  author's  care  a 


Fig.  722. — Repair  of  a  stellate  tear  of  the  cervix. 

Le  Fort  operation  on  the  vagina  had  been  performed  by  another 
operator  three  years  before;  on  examination  a  row  of  silver  sutures 
was  found  extending  across  the  vagina,  v/here  they  had  been  for 
hree  years.  There  was  complete  atresia,  with  extremely  firm  cica- 
tricial contraction,  a  pyelythrometra,  which  had  ruptured  into  the 
bladder,  an  extensive  vesicovaginal  fistula  above  the  site  of  atresia, 
double  pyosalpinx,  and  a  general  septic  intoxication.  The  patient 
was  cured  by  a  hysterectomy  and  the  removal  of  the  uterine  ap- 
pendages. With'  no  further  discharge  into  the  upper  vagina  the 
vesicovaginal  fistula  closed  spontaneously.  The  atresia  was  not 
corrected,  as  the  only  purpose  of  such  treatment  would  have 
been  to  establish  a  coitional  vagina,  vv^hich  is  not  always  prac- 
ticable in  the  absence  of  the  uterus.     Even  were  permanent  sue- 


OPERATIONS   ON  THE    VAGINA. 


897 


cess  assured,  the  propriety  of  medical  treatment  to  that  end  is 
questionable. 

Sneguireffi  has  thrice  successfully  performed  a  curious  operation  for  making  a 
coitional  vagina  :  An  incision  is  made  alongside  the  sacrum  and  coccyx  ;  the  latter  is 
excised ;  the  rectum  is  freed  for  3  inches  above  the  anus  and  is  cut  across  at  the 
level  of  the  third  sphincter  ;  the  end  of  the  upper  segment  is  implanted  below  the  tip 
of  the  sacrum  ;  the  upper  end  of  the  lower  segment  is  closed  by  sutures  ;  a  knife 
divides  the  whole  length  of  the  septum  between  the  lower  segment  of  rectum  and  the 
blind  pouch  representing  the  vagina;  the  mucous  membranes  of  the  two  pouches  are 
sewed  together.  It  is  claimed  that  continence  of  gas  and  feces  is  finally  established. 
Isaacs  -  has  made  a  coitional  vagina  by  a  circular  incision  around  the  site  of  the  intro- 
itus ;  pushing  the  skin  thus  detached  in  to  a  depth  of  -^Yt.  inches  and  applying 
Thiersch's  grafts  between  the  sides  of  the  glass  vaginal  plug  and  the  raw  surface  of 
the  artificial  canal. 


Fig.  723.  —  I,  Denudation    for   repair  of  lacerated   cervix  ;   2,    sutures   inserted  ;   3, 

sutures  united. 


Operations  on  the  cervix  for  the  injuries  of  parturition  are 
two  in  number:  trachelorrhajjhy  and  amputation.  Trachelor- 
rhaphy is  required  for  bilateral  laceration  and  may  also  be  utilized 

1  "  Zwei  neue  Falle  von  Restitutio  vaginae  per  transplantationem  ani  et  recti," 
"  Zentralbl.  f.  Gyn.,"  No.  24,  1904. 

^  "  N.  Y.  Med.  Record,"  Nov.  19,  1904. 
57 


898 


OBSTETRIC   OPERATIONS. 


for  the  cure  of  stellate  lacerations.  Repair  of  a  lacerated  cervix 
cannot  be  undertaken  until  after  the  fifth  day  of  the  puerperium 
on  account  of  the  danger  of  infecting  the  endometrium.  The 
best  time  is  at  the  end  of  the  first  week,  when  the  danger  of  in- 
fection, with  a  satisfactory  technic,  is  over.  It  is  the  necessity 
of  postponing  the  cervical  operation  which  imposes  delay  upon 
the  operator  in  repairing  the  other  injuries  of  childbirth.  More- 
over, better  results  can  be  obtained,  both  in  diagnosis  and  treat- 
ment of  all  the  injuries  of  the  birth-canal,  if  the  bruising,  edema, 
and  distortion  of  the  tissues  present  immediately  after  labor  has 


Fig.  724. — Hegar's  amputation  :   Stitches  introduced. 


disappeared.  The  argument  against  intermediate  operations  that 
the  flow  of  lochia  over  unclosed  wounded  surfaces  predisposes  to 
sepsis  is  fallacious.  The  author's  experience  during  the  last  six 
years,  in  which  the  intermediate  as  against  immediate  operations 
have  been  uniformly  preferred,  justifies  this  statement. 

For  trachelorrhaphy  the  two  lips  of  the  cervix  are  seized  with 
double  tenacula  and  pulled  down,  an  Auvard's  speculum  retracting 
the  posterior  vaginal  wall.  Denudation  is  resorted  to  if  necessary. 
The  raw  surfaces  are  united  with  interrupted  sutures  of  chromic 
gut.  Care  must  always  be  exercised  to  leave  a  wide  cervical 
canal  (Fig.  723).  For  amputation  of  the  cervix,  which  is  required 
when  the  injury  or  sloughing  leaves  a  condition  irreparable  by 
plastic  surgery,  a  circular  incision  is  made  above  the  site  of  the 


PREPARATION  FOR  ABDOMINAL    OPERATIONS.  899 

injuries  and  the  cervix  is  amputated  in  healthy  tissue.  The 
sutures  of  chromic  gut  are  inserted  according  to  the  modified 
Hegar  plan  as  illustrated  in  Fig.  724, 

Vaginal  section  is  required  for  vaginal  hysterotomy,  for  vagi- 
nal Cesarean  section,  for  pelvic  abscess,  for  hematocele;  possibly 
for  ectopic  pregnancy  and  for  inflammation  of  the  appendages. 
The  vaginal  vault  may  be  opened  posteriorly  or  anteriorly:  in  the 
former  case  by  a  transverse  incision  through  the  vaginal  wall  of 
the  posterior  vault,  the  cervix  being  pulled  down  with  a  tenaculum; 
the  peritoneum  is  opened  with  sharp-pointed  scissors.  In  the 
latter  case  the  cervix  is  pulled  down,  a  T-shaped  incision  is  made, 
the  vaginal  flaps  are  dissected  back,  the  uterovesical  ligament  is 
cut,  and  the  peritoneum  is  opened  with  scissors. 

Myomectomy  by  the  vaginal  route,  possibly  required  for  the  re- 
moval of  such  a  tumor  as  is  represented  in  Fig.  558,  is  best  per- 
formed by  an  anterior  vaginal  section;  an  anterior  median  hyster- 
otomy, extending  through  the  cervix  and  high  enough  to  give  ac- 
cess to  the  base  of  the  tumor,  the  cervix  being  steadied  and  pulled 
down  by  tenacula.  The  uterine  wound  is  united  by  a  double-tier 
stitch  of  chromic  gut,  the  vaginal  wall  is  closed  with  interrupted 
sutures,  and  the  vesico-uterine  pouch  is  drained  by  a  gauze  strip. 
The  vagina  is  packed. 

PREPARATION  FOR  ABDOMINAL  OPERATIONS. 

For  private  house  operations — emergency  ectopic  pregnancy 
operations.  Cesarean  sections,  etc. — the  operator  takes  with  him 
a  portable  steriHzer  containing  the  following  articles:  12  towels; 
20  pieces  of  folded  gauze;  i  large  pad  of  absorbent  cotton;  4  sheets; 
3  long-sleeve  gowns;  i-inch  bandage;  6-inch  bandage;  i  glass  tube 
of  plain  packing;  6  brushes;  2  rubber  sheets;  package  of  gauze  pads; 
tubes  of  celloidin  thread  and  catgut;  the  necessary  instruments, 
and  a  portable  operating  table.  A  list  is  furnished  of  things  to 
have  in  readiness  in  the  house  (p.  864). 

The  preparation  of  the  patient's  skin  has  been  described.  The 
abdominal  dressing  is  turned  down  on  the  woman's  thighs;  the 
abdomen  is  covered  with  a  piece  of  sterile  rubber  dam,  18  inches 
square.  A  sterile  sheet  is  folded  over  the  patient's  thighs  and  legs; 
another  one  over  her  chest.  Four  towels  surround  the  field  of 
operation,  secured  by  clips,  as  illustrated  in  Fig.  725.  A  cut  with 
scissors  is  made  through  the  rubber  dam;  the  skin  is  incised;  then 
the  fat  and  fascia  with  a  knife;  the  rectus  muscle  is  split  with  the 
fingers;  the  rubber  dam  is  sewed  in  the  wound  with  a  stitch  on  either 
side,  so  that  its  edges  are  folded  into  the  wound  (Fig.  726) ;  the  peri- 
toneum is  caught  by  two  hemostats  and  incised  between  them. 


900 


OBSTETRIC  OPERATIONS. 


The  abdominal  wound  is  closed  by  a  running  stitch  of  No.   i 
chromic  gut  in  the  peritoneum;  two  interrupted  sutures  and  a 


Fig.  725. — A  sheet  of  rubber  dam  over  the  abdomen,  surrounded  by  towels. 


Fig.  726. — The  rubber  dam  split  with  scissors  and  the  abdomen  incised  to  the 
peritoneum.  The  edges  of  the  rubber  dam  are  sewed  in  the  wound  with  two  sutures, 
so  that  they  cover  the  skin  and  fold  into  the  wound. 


running  suture  of  the  same  sized  gut  in  the  fascia;  a  double-tier 
suture  of  No.  o  gut  in  the  fat  and  a  subcuticular  stitch  of  silkworm 
gut,  which  gives  a  permanently  narrow  scar.   The  stitch  is  removed 


PREPARATION  FOR   ABDOMINAL    OPERATIONS. 


901 


on  the  tenth  or  twelfth  day.  The  wound  is  sealed  with  inch  wide 
strips  of  gauze  and  collodion.  A  pad  of  gauze  and  adhesive  straps 
are  put  over  the  collodion  dressing,  which  is  dusted  with  sterile 
talcum  powder  to  prevent  its  sticking  to  the  upper  dressing.  The 
pads  and  straps  are  removed  in  forty-eight  hours,  leaving  nothing 
on  the  abdomen  but  the  narrow  strip  of  gauze  and  collodion  dress- 
ing, which  is  removed  in  ten  to  twelve  days.  The  patient  is  allowed 
considerable  liberty  of  movement  in  bed.  She  is  given  cool  water 
to  quench  her  thirst  as  soon  as  she  asks  for  it;  the  feeding  is  al- 
bumen-water, broths,  barley-water,  and  tea,  begun  in  twenty-four 
hours.  At  the  end  of  forty-eight  hours  she  gets  a  course  of  calo- 
mel in  divided  doses;  on  the  third  day  a  saline  laxative  in  2-ounce 


Fig.  727. 


-Abdominal  wound  sealed  with  collodion  and  gauze.     The  only  dressing 
on  the  abdomen  after  forty-eight  hours. 


doses,  two  hours  apart,  till  6  to  8  ounces  are  taken.     (I  prefer 
Sprudel  water  and  Carlsbad  salts  or  citrate  of  magnesia.) 

Drainage  is  provided  by  gauze,  by  tubes,  by  the  horsehair  capil- 
lary drain,  and  by  gravity  through  an  opening  in  the  dependent 
portion  of  the  area  to  be  drained.  The  gauze  drain  is  used  in  the 
following  forms:  In  the  shape  of  a  pack,  filling  a  cavity  flush  with  the 
exterior;  as  a  pack,  communicating  with  the  exterior  by  a  strij);  as  a 
wick  rolled  on  itself;  as  a  wick  protected  in  a  part  of  its  length  by 
rubber  covering ;  as  a  wick  with  alternate  layers  of  gauze  and  rubber — 
the  cigarette  drain.  The  tube  is  curved  or  straight  and  of  glass  or 
rubber.  To  prevent  its  slipping  out  of  a  cavity  in  which  it  drains 
the  most  dependent  portion,  as  in  Douglas'  pouch  through  the 
posterior  vaginal  vault,  it  must  have  a  T  shape.  The  most  suitable 
form  of  drainage  for  a  given  case  must  be  chosen  by  the  operator 


902 


OBSTETRIC   OPERATIONS. 


at  the  time  of  operation,  his  choice  being  guided  by  good  judgment 
and  experience.  The  most  thorough  drainage  is  secured  by  the 
combination  of  the  curved  glass  tube  and  the  gauze  pack,  the 
former  being  placed  in  Douglas'  pouch,  and  the  latter  filling  the 
pelvis  and  emerging  alongside  the  tube  at  the  lower  angle  of  the 
abdominal  wound. 

Drainage  is  almost  invariably  required  in  streptococcic  suppura- 
tion; in  other  conditions  in  the  peritoneal  cavity  it  should  be 
avoided  if  possible. 

Hysterectomy  or  removal  of  the  uterus  is  required  for  suppura- 
tive metritis  or  perimetritis,  for  streptococcic  necrosis,  neoplasms 
of  the  uterus,  rupture  of  the  walls,  in  the  Porro  Cesarean  section, 


Fig.    728. — Ligation  of  the  ovarian  artery  and  tlie   artery  of  the   round  ligament: 
division  of  the  broad  ligament  between  clamps. 


in  exceptional  cases  of  inversion,  and  in  irreducible  incarceration 
of  a  displaced  uterus.  It  is  an  operation  of  election  if  the  append- 
ages are  remo\'ed. 

The  hysterectomy  may  be  partial  or  total;  it  may  be  performed 
by  the  abdominal  and  by  the  vaginal  route  or  by  both  combined. 

Partial  hysterectomy  includes  exsection  of  wedge-shaped 
pieces  of  the  wall  (cuneiform  hysterectomy),  and  amputation  of 
the  uterus  at  the  level  of  the  internal  os.  The  first  consists  in 
excising  with  a  knife  a  portion  of  the  uterine  wall,  as  at  the  fundus  or 


PREPARATION  FOR   ABDOMINAL    OPERATIONS.  903 

the  cornua  for  streptococcic  necrosis,  uniting  the  myometrium 
with  a  two-tier  suture  of  chromic  gut,  and  closing  the  perimetrium 
with  a  lace  suture  of  chromic  gut,  as  in  a  Cesarean  section  (Fig. 
680).  The  second  consists  of  the  foHowing  steps :  Ligation  of  the 
ovarian  arteries;  ligation  of  the  arteries  of  the  round  ligament; 
fastening  a  hemostat  above  the  ligatures  on  the  broad  ligament; 
clamping  the  whole  breadth  of  the  broad  ligament  above  the  hemo- 
stats;  cutting  through  the  broad  ligament  in  an  oblique  direction 
downward  to  the  level  of  the  internal  os;  clamping  the  uterine 
arteries  as  they  are  cut;  preparing  peritoneal  flaps  on  the  anterior 
and  posterior  walls  of  the  lower  uterine  segment;  cutting  through 
the  cervix  and  removing  the  womb;  ligating  the  uterine  arteries; 
sewing  together  the  peritoneal  flaps  and  the  edges  of  the  broad  liga- 
ment.    The  suture  for  the  last-named  purpose  can  be  run  from 


Fig.  729. — Closure  of  peritoneum  over  the  stump  after  hysterectomy  by  supravaginal 
amputation  of  the  uterus. 

side  to  side;  or  can  be  begun  in  the  middle  of  the  cervix,  anteriorly, 
uniting  the  anterior  surfaces  of  both  broad  ligaments  to  one  another, 
the  posterior  surfaces  in  the  same  way,  and  ending  at  the  middle  of 
the  cervix  posteriorly.  The  latter  jjlan,  if  jjracticable,  has  the  ad- 
vantage of  bringing  the  raw  surfaces  of  the  stumps  of  the  outer 
portions  of  the  broad  ligament  face  to  face  and  covering  them. 
Panhysterectomy  may  be  required  for  septic  infection  and  is  neces- 
sary for  malignant  neoplasms.  The  steps  are  the  same  as  in  ampu- 
tation of  the  womb  at  the  cervix,  except  that  after  cutting  the  uterine 
arteries,  the  cervix  and  the  upper  i)ortion  of  the  vagina  are  dissected 
clear  of  all  their  attachments;  two  right-angled  clamps  are  fastened 
on  the  vaginal  walls;  the  vagina  is  cut  across  between  them;  several 
interrupted  sutures  unite  the  vaginal  walls  and  the  peritoneal 
edges  are  closed  as  before  described.     In  ojjerations  for  septic 


904 


OBSTETRIC   OPERATIONS. 


infection  a  gauze  drain  leading  into  the  vagina  is  placed  under  the 
peritoneum.  Preparatory  to  this  operation  the  vulva  and  vagina 
are  carefully  cleansed  and  the  latter  is  packed  with  sterile  gauze. 
Vaginal  hysterectomy  has  a  narrow  field.  For  some  septic 
and  necrotic  conditions  of  the  uterus,  for  some  malignant  neoplasms 
with  extensive  sloughing,  for  incarcerated  prolapse  and  retro- 
flexion with  gangrene,  it  may  be  preferred.  The  vaginal  vault  is 
opened  anteriorly  and  posteriorly;  the  vaginal  wall  is  cut  laterally;, 
the  broad  ligaments  are  secured  by  ligatures  or  clamps,  the  latter 
often  being  much  the  easier  method,  and  after  they  are  cut  the 


Fig.  730.^Insertion  of  pedicle  needle  under  ovarian  ligament  and  close  to  uterus  for 
salpingo-oophorectomy. 


uterus  is  removed.  It  usually  facilitates  the  operation  to  bisect 
the  uterus  before  securing  and  severing  the  broad  ligaments. 

Combined  hysterectomy  has  also  a  limited  application.  Either 
the  abdomen  is  first  opened,  the  broad  ligaments  ligated  and  cut, 
as  already  described,  and  the  vaginal  attachments  of  the  uterus 
severed  from  below;  or,  the  vaginal  part  of  the  operation  is  first 
performed  and  the  hysterectomy  completed  from  above. 

Salpingo=oophorectomy,  indicated  for  infectious  inflammations, 
neoplasms,  ectopic  pregnancy,  and  to  establish  the  menopause,  as 
in  cases  of  ill-developed  uterus  (p.  66),  may  be  performed  in  the 
following  routine  manner:    The  tube  is  cut  off  from  the  uterus 


PREPARATION  FOR  ABDOMINAL    OPERATIONS.  905 


Fig.  731. — Cutting  tube  from  cornu,  so  as  to  have  no  tubal  stump. 


Fig.  732. — Insertion  of  second  ligature,  to  be  tied  anmnd  the  outer  edge   of  the 

broad   ligament. 


9o6 


OBSTETRIC   OPERATIONS. 


Fig.    733. — The    whole    breadth    of    the    broad   ligament    surrounded    by    the    two 

ligatures. 


Fig.  734. — Tube  and  ovary  cut  away. 


PREPARATION  FOR  ABDOMINAL    OPERATIONS. 


907 


at  the  cornu,  leaving  no  tubal  stump;  a  catgut  ligature  (size  3, 
chromic)  is  carried  through  the  broad  ligament  by  a  pedicle  needle 
below  the  ovarian  ligament  and  inside  the  round  ligament;  it 
is  tied  over  the  broad  ligament  between  the  uterus  and  the  cut 
uterine  end  of  the  tube.  Another  ligature  is  inserted  below  and 
inside  the  first;  it  is  tied  over  the  outer  edge  of  the  broad  ligament 
below  the  ovary.  A  hemostat  is  fastened  over  the  broad  ligament 
above  each  knot.  The  tube  and  ovary  are  removed  by  severing 
the  puckered   broad   ligament   above  the  hemostats.     The  raw 


Fig.  735. — Cornual  wound  closed. 


surface  at  the  uterine  cornu  is  united  with  a  double-tier  suture  of 
catgut. 

The  technic  of  ligating  the  broad  ligament  may  be  varied  in 
the  following  ways:  if  it  is  desired  to  remove  the  tube  alone  and 
not  the  ovary  (salpingectomy),  the  second  ligature  is  tied  above 
the  ovary  and  below  the  abdominal  ostium  of  the  tube.  If  the 
broad  ligament  is  too  thick  to  be  included  in  a  mass  ligature,  the 
vessels  are  cither  tied  separately  where  they  bleed,  or  the  ovarian, 
the  uterine,  and  the  round  ligament  arteries  arc  ligated  separately, 
as  in  Fig.  736.  The  upper  cut  edges  of  the  broad  ligament 
should  be  left  gaping  if  the  intraligamentary  space  is  infected, 
the  abdomen  being  drained;  or  in  non-infected  cases  the  edges 
of  the  broad  ligament  are  whipped  together. 


9o8 


OBSTETRIC   OPERATIONS. 


Fig.  736. — Ligatures  tied  ;  tube  and  ovary  removed  with  wedge-shaped  exsection  of 

uterine  cornu. 


Fig.  737. — Inserting  a  chain  ligature  in  the  broad  hgament. 


Fig.  738. — The  loops  of  the  chain  ligature  are  cut,  the  ends  intertwined  and  tied. 


PREPARATION  FOR  ABDOMINAL    OPERATIONS. 


909 


Fig.    739. — Excision  of  tubal   wall  for   sterility  from   occlusion   of   the    abdominal 

orifice. 


Fig.  740. — .Suspension  of  the  ovary  by  shortening  the  infundibulopelvic  liga- 
ment:  I.  Suture  inserted  ;  2,  suture  tightened.  By  making  three  insertions  of  the 
needle  there  is  no  loophole  left  between  the  edges  of  the  broad  ligament. 

If  the  broad  ligament  is  so  much  increased  in  breadth,  as  in 
some  ovarian  and  broad  ligament  tumors,  that  the  mass  ligature 
is  not  to  be  trusted,  the  chain  ligature  is  required  (Fig.  737). 


9IO  OBSTETRIC   OPERATIONS. 

If  only  a  part  of  the  tube,  say  the  outer  third,  is  removed,  it  is 
cut  away;  the  vessels  are  tied  separately  where  they  bleed  and  the 
mucous  membrane  of  the  tube  is  united  to  its  peritoneal  investment 
by  four  interrupted  catgut  stitches  (partial  salpingectomy). 

If  the  ovary  alone  is  removed,  a  ligature  is  carried  through  the 
middle  of  the  mesovarium;  it  is  tied  in  both  directions  around  the 
mesovarium;  the  ovary  is  cut  away  above  the  ligature.  If  a  dis- 
eased portion  only  of  an  ovary  is  removed,  a  wedge-shaped  exsec- 
tion  is  performed,  the  cuneiform  wound  being  united  by  close  set 
interrupted  sutures  of  catgut. 

Suspension  of  the  ovary  is  indicated  for  prolapse  due  to  length- 
ening of  the  infundibulopelvic  ligament  if  the  patient  complains 
of  symptoms  severe  enough  to  demand  relief — namely,  pelvic  pain, 
nausea,  and  dyspareunia.  The  operation  consists  in  inserting  a 
needle  and  celloidin  thread  first,  close  to  the  ovary  and  just  under 
the  ligament,  next  about  J  inch,  and  then,  finally,  about  an  inch 
or  more  away  from  the  ovary.  By  tying  the  ends  of  the  thread 
the  ligament  is  shortened  by  the  distance  between  the  first  and  . 
third  insertion  of  the  needle. 

If  the  operation  on  the  tube  is  to  restore  its  patency  on  account 
of  closure  of  the  abdominal  ostium,  either  partial  salpingectomy 
or  salpingostomy  is  required  (Fig.  739).  The  latter  operation 
consists  in  buttonholing  the  tube  on  its  upper  aspect  near  the  ab- 
dominal extremity  and  uniting  its  mucous  lining  to  its  peritoneal 
investment  by  a  few  interrupted  sutures. 

Exsection  of  Abdominal  and  Pelvic  Tumors  by  Abdominal 
Section. — The  removal  of  ovarian  cysts;  the  enucleation  of  par- 
ovarian cysts;  myomectomy  for  fibromyomata  of  the  uterus  and 
of  the  broad  ligament  are  not  infrequently  indicated  in  the  child- 
bearing  woman. 

Oophorectomy  for  pseudomucin,  serous  cystadenomatous,  simple 
retention  and  serous,  lutein,  and  dermoid  cysts,  teratomata,  fibro- 
mata, and  the  malignant  tumors  is  accomphshed  by  transfixion  and 
ligation  of  the  mesovarium  or  of  the  broad  ligament,  as  already 
described  in  the  technic  of  salpingo-oophorectomy.  The  chain 
ligature  is  required  for  a  broad  pedicle.  If  the  operation  is  per- 
formed after  delivery  when  the  involution  of  the  uterus  is  far  ad- 
vanced or  accomplished,  the  uterus  should  be  suspended  to  prevent 
the  adherent  retroversion  which  is  a  common  sequel  of  the  removal 
of  ovarian  tumors.  If  the  cyst  is  twisted  on  its  pedicle,  the  pedicle 
should  be  untwisted  and  the  ligatures  placed  in  the  broad  ligaments 
beyond  the  thrombus,  which  is  usually  seen  in  the  ovarian  vein. 
The  cyst  should  not  be  punctured  if  its  contents  might  contami- 
nate the  peritoneum  or  cause  implantation  metastases.  If  the 
operation  is  undertaken  in  pregnancy  the  following  rules  should 


PREPARATION  FOR  ABDOMINAL    OPERATIONS.  9I  I 

be  observed:  In  early  pregnancy  not  to  disturb  the  pregnant 
uterus;  in  operations  near  term  to  perform  a  coincident  Cesarean 
section  and  to  remember  the  unusually  large  proportion  of  dermoids 
found  among  ovarian  cysts  in  pregnant  women  (one-quarter),  and 
therefore  not  to  puncture  the  cyst  if  there  is  any  doubt  about  its 
contents. 

The  enucleation  of  broad  ligament  tumors  is  accomphshed 
by  incising  the  anterior  face  of  the  broad  ligament,  shelling  out 
the  tumor  from  its  bed,  removing  redundant  portions  of  the  broad 
ligament  capsule,  obliterating  as  far  as  possible  the  raw  bed  of  the 
tumor  by  tier  sutures  or  draining  the  cavity  by  vaginal  puncture, 
packing  the  cavity  with  gauze,  and  uniting  the  peritoneum  above  it. 
^Myomectomy  for  uterine  fibromata  requires  ligation  of  the  pedicle 
if  it  is  small  enough  (no  larger  than  one's  thumb),  exsecting  it  by 
a  wedge-shaped  incision  if  it  is  too  large  to  ligate,  or  sphtting  its 
capsule  and  shelling  it  out,  the  bed  of  the  tumor  being  completely 
obliterated  by  tier  sutures.  If  myomectomy  is  required  near  term 
or  during  labor,  a  Cesarean  section  should  be  part  of  the  operation. 
The  operator  must  remember  that  it  is  usually  safer  to  remove  the 
uterus  after  it  is  evacuated,  but  in  a  case  peculiarly  suitable  for 
myomectomy  alone,  it  is  perfectly  possible  to  leave  the  uterus 
intact. 

Inguinal  section  is  required  for  the  removal  of  fibromyomata 
of  the  round  ligament  and  for  shortening  the  round  ligaments. 
For  the  first  purpose  an  incision  the  length  of  the  tumor  is  made 
parallel  with  Poupart's  ligament  through  the  skin,  fat,  and  trans- 
versalis  fascia.  The  tumor  is  shelled  out  if  possible  without  open- 
ing the  peritoneal  cavity.  The  base  of  the  tumor,  however,  may 
be  adherent  to  the  peritoneum,  in  which  case  a  wide  opening  into 
the  peritoneal  cavity  is  required.  The  wound  is  closed  so  that 
the  inguinal  canal  is  obliterated,  as  in  the  Bassini  operation;  the 
oblique  muscle  is  joined  to  the  peritoneum  at  the  base  of  the  canal 
and  to  Poupart's  ligament  by  a  tier  stitch;  the  fascia  is  united  by 
a  running  stitch;  the  fat  and  superficial  fascia  by  a  double-tier 
stitch  of  No.  o  unchromicized  gut;  the  skin  by  a  subcuticular  stitch. 

For  retrodis placement  of  the  uterus  the  following  treatment 
should  be  tried :  If  the  uterus  is  displaced  at  the  end  of  the  third 
week  of  the  puerperium  it  should  be  replaced  and  the  knee-chest 
posture  twice  a  day  recommended.  If  the  uterus  is  displaced  at 
the  end  of  six  weeks  it  should  be  replaced,  a  suitable  ])essary 
inserted,  and  left  in  jjlace  for  eight  weeks. 

During  this  time  the  ])atient  should  be  placed  in  charge  of  an 
expert  masseuse  and  should  ])ractice  Swedish  movements  of  the 
trunk  and  thighs  (resisted),  followed  by  abdominal  massage.  At 
the  end  of  eight  weeks  the  pessary  is  removed.     Examinations  are 


912 


OBS  TE  TRIG   OPERA  TIONS. 


Fi".  741. — The  insertion  of  a  pessary.  It  is  turned  almost  upside  down  and  in- 
serted obliquely  in  the  vulvar  orifice.  As  it  is  pushed  upward  and  backward  it  is 
rotated  nito  proper  position;  this  movement  brings  the  back  bar  in  front  of  the 
cervix ;  the  forefinger  slipped  over  it  pushes  it  backward  over  the  cervix  into  the 
posterior  vaginal  vault. 


,V*"^3 


Fig.  742. — The  retroversion  pessary   in    position.     The  arrow  shows  the  direction  of 
the  traction  of  the  posterior  vaginal  wall  upon  the  cervix. 


PREPARATION  FOR  ABDOMINAL    OPERATIONS.  913 


Fig.  743. — Round  ligament  freed,  but  not  )et  detached. 


Fig.  744. — Round  ligamenl.s  pulled  out  of  inguinal  canaU  four  to  .si.\  inches. 


58 


914 


OBSTETRIC   OPERATIONS. 


made  at  intervals  of  two  weeks,  a  month,  and  two  months.  If  at 
this  last  examination  the  uterus  still  remains  in  good  position  with- 
out artificial  support,  the  patient  is  probably  cured,  although  more 
liable  to  retrodisplacement  of  the  uterus  than  the  average  woman. 
If  the  displacement  recurs  within  three  months  after  the  removal  of 
the  pessary,  the  patient  must  choose  between  its  indefinite  use  and 
a  radical  cure  by  operation. 

Of  all  the  operations  for  retrodisplacement  of  the  uterus,  more 
can  be  said  in  favor  of  shortening  the  round  ligament  in  the  groin 


Fig.  745. — Round  ligaments  crossed  and  fastened  together  in  mid-line. 

than  of  any  other.^  In  fifteen  years  and  In  more  than  100  operations 
I  have  not  seen  a  single  recurrence,  though  some  of  my  patients 
have  had  three  children  since  the  operation;  no  one  anywhere  has 
ever  reported  a  serious  disturbance  of  a  subsequent  pregnancy  on 
account  of  the  operation,  and  it  is  entirely  free  from  risk.  It 
can  be  performed  at  any  time  after  the  fourteenth  to  seventeenth 
day  of  the  puerperium.     As  much  cannot  be  said  for  any  of  the 

1  Proposed  by  Alquie  in  1S40;  performed  by  Alexander  in  1881  and  described 
in  1883  ;  performed  and  described  by  Adams  in  1882.  Hence,  it  is  sometimes  re- 
ferred to  by  the  clumsy  title  of  the  "  Alquie-Alexander- Adams  operation." 


PREPARATION  FOR   ABDOMliVAL    OPERATIONS. 


915 


Other  operations.  Unfortunately,  it  is  only  to  be  recommended  if 
there  is  no  suspicion  of  intrapelvic  adhesions  or  disease,  or  of 
appendicitis. 

The  operator  places  his  forefinger  on  the  pubic  spine,  his  thumb 
on  Poupart's  ligament,  about  an  inch  and  a  half  intervening  be- 
tween the  two.  The  points  of  the  forefinger  and  of  the  thumb  are  then 
moved  upward  about  a  quarter  of  an  inch  and  an  incision  through 
the  skin  is  made  between  them.  The  fat  and  superficial  fascia 
are  divided  to  the  deep  fascia.  Several  blood-\'essels  are  severed, 
the  bleeding  ends  of  which  must  be  seized  by  hemostats.     All  the 


Fig.  746. — Deep  tier  of  buried  running  suture  of  formalin  catgut,  embracing  in- 
ternal oblique  and  transversalis  muscles,  round  ligament,  and  Poupart's  ligament. 
Deep  part  of  uppermost  loop  of  suture  (not  showing  in  cut)  passes  at  level  of  and 
embraces  margins  of  internal  ring:  .f,  Skin;  s.  c.f.,  subcutaneous  fat  ;  a.  e.  o.,  apon- 
eurosis of  external  oblique;  /.  o.,  internal  oblique  muscle;  r.  /.,  round  ligament; 
/'.  /. ,  Poupart's  ligament. 


bleeding  must  be  controlled  before  the  deep  fascia  is  opened,  other- 
wise the  difficulty  of  finding  the  round  ligaments  is  much  increased. 
The  fascia  is  incised  just  above  Poupart's  ligament,  the  incision 
running  through  the  pillars  of  tlie  external  inguinal  ring.  On  the 
])Osition  of  the  incision  depends  the  ease  with  which  the  round 
ligaments  are  found.  If  it  is  too  high,  they  may  not  be  located  at 
all,  or  only  with  such  dift'iculty  and  delay  that  the  o])eration  is 
scarcely  justifiable.  The  inguinal  canal  being  laid  open  by  the 
division  of  the  fascia,  the  edges  of  the  wound  are  retracted  with 


gi6  OBSTETRIC   OPERATIONS. 

forked  retractors.  The  round  ligament  is  at  once  seen  as  a  whitish 
or  pinkish  cord  about  as  large  as  a  slate  pencil,  running  along  the 
floor  of  the  canal.  It  is  picked  up  by  a  blunt  hook  and  gently 
drawn  out  of  the  internal  ring,  the  genitocrural  nerve  which  ac- 
companies it  being  avoided.  The  peritoneal  investiture  which  soon 
appears  is  stripped  back  by  a  gauze  pad  and  the  ligament  is  pulled 
out  until  it  is  freed  for  at  least  four  inches.  It  becomes  thicker  and 
stronger  as  it  em.erges  from  the  internal  ring,  until  it  may  reach 
almost  half  the  caliber  of  one's  little  finger.  One  ligament  being 
extracted,  the  wound  is  covered  with  a  gauze  pad  and  the  other 
groin,  opposite  the  operator,  is  opened  in  the  same  way,  except 
that  if  the  operator  stands  on  the  patient's  right  hand,  the  thumb  of 
his  left  hand  marks  the  position  of  the  pubic  spine  and  the  fore- 
finger is  placed  upon  Poupart's  ligament  about  one  and  a  half  inches 
away. 

Difficulty  may  be  encountered  in  finding  the  round  ligaments 
if  they  are  small  and  ill-developed,  if  they  pursue  an  abnormal 
course  outward  and  upward,  or  if  they  are  abnormally  placed  above 
their  usual  situation  and  behind  the  oblique  muscle. 

Both  ligaments  being  freed  as  far  as  possible  (at  least  four 
inches,  oftener  more),  they  are  pulled  upon  by  an  assistant,  while 
the  operator  lays  his  outspread  hand  upon  the  hypogastrium,  against 
which  he  feels  the  fundus  uteri  bump  as  the  ligaments  are  pulled 
upon.  The  terminal  ends  of  the  ligaments  are  cut  off,  they  are 
crossed  in  the  middle  line  over  the  m^ons  veneris,  and  a  hemostat 
fastens  them  both  where  they  cross  to  insure  an  equal  amount  of 
traction  on  each  when  they  are  sewed  fast  in  the  inguinal  canal. 

The  sutures  are  now  inserted.  A  strand  of  catgut  (size  No.  i) 
on  a  curved  needle  is  passed  through  the  fascia  at  the  upper  angle 
of  the  wound,  the  end  remaining  loose,  not  knotted;  the  needle  then 
passes  through  the  internal  oblique  muscle,  goes  through  the  center 
of  the  round  ligament,  picks  up  the  flpor  of  the  inguinal  canal,  and 
finally  passes  through  Poupart's  ligam_ent.  Four  or  five  turns  are 
thus  taken,  in  the  same  order,  each  one  passing  through  the  center 
of  the  round  ligament  until  the  external  pillars  of  the  ring  are  united. 
The  next  turn  of  the  needle  passes  under  the  round  ligament,  oblit- 
erating the  external  ring  from  above  downward.  All  the  redun- 
dant portion  of  the  round  ligament  is  cut  off;  the  same  needle  and 
thread  are  then  passed  through  the  fascia  alone  midway  between 
the  turns  of  the  continuous  suture  already  in  place,  until  the  suture 
ends  opposite  the  point  where  it  began  and  is  knotted  in  a  triple 
knot,  the  only  one  required.  The  superficial  fascia  and  fat  are 
joined  by  a  continuous  fine  catgut  suture  in  two  tiers.  The  skin  is 
united  by  a  continuous  suture  of  catgut  or  an  intracutaneous  stitch, 
as  the  operator  prefers.     The  groin  wound  nearest  the  operator 


PREPARATION  FOR   ABDOMINAL    OPERATIONS.  917 

being  closed,  the  other  one  is  treated  in  the  same  way,  except  that 
a  right-handed  man  naturally  passes  the  needle  in  reverse  order 
through  Poupart's  ligament,  floor  of  inguinal  canal,  round  liga- 
ment, oblique  muscle,  and  fascia.  As  the  round  ligament  is  sewed 
in  place  an  assistant  holds  the  hemostat,  keeping  it  in  the  middle 
line  of  the  mons  veneris,  so  as  to  insure  equal  traction  on  both  sides. 
The  wounds  are  covered  with  gauze  and  collodion.  It  is  safer, 
but  not  necessary,  to  insert  a  pessary  before  shortening  the  round 
ligaments,  which  remains  in  place  for  six  weeks  after  the  operation. 
A  convenient  time  to  insert  the  pessary  is  after  the  curetment,  which 
ordinarily  precedes  an  Alexander  operation,  for  almost  every  case 
of  retroversion  is  complicated  by  a  chronic  endometritis  with 
menorrhaffia  and  leukorrhea. 


Fig.  747. — Suspension  suture  tlirough  fundus  uteri,  peritoneum,  and  a  part  of  the  recti 

muscles. 


Abdominal  Operations  for  Retrodisplacement  of  the  Uterus. — 

Of  the  numerous  operations  devised  for  the  purpose,  the  author 
avails  himself  now  of  only  two — namely,  uterine  suspension  and 
the  Baldy  operation. 


91 8  OBSTETRIC   OPERATIONS. 

Uterine  Suspensions—While  this  operation  has  been  so  gener- 
ally available  that  it  has  been  more  frequently  utilized  than  any 
other,"  it  has  many  objectionable  features:  The  attachment  of 
the  fundus  uteri  to  the  abdominal  wall  is  unnatural;  the  suspensory 
ligament  if  made  too  weak  will  not  maintain  the  uterus  in  good 
position  long  and  does  not  survive  a  subsequent  pregnancy;  if,  on 
the  contrary,  it  is  made  too  firm  (uterine  fixation),  there  may  be 
serious,  even  fatal  complications,  in  a  subsequent  pregnancy  or 
labor.  Nevertheless,  it  is  quick,  easy  to  perform,  and  has  fulfilled 
its  purpose  fairly  weU,  so  that  its  vogue  has  been  extensive  until 
something  better  is  devised  to  supplant  it.  The  technic  of  the 
operation  is  as  follows:  After  opening  the  abdomen,  two  stitches 
of  fine  celloidin  linen  thread  are  passed  through  the  peritoneum, 
a  part  of  the  rectus  muscle,  the  perimetrium,  and  about  an  eighth 
of  an  inch  of  the  myometrium  of  the  fundus,  as  illustrated  in  Fig. 
747.  As  these  stitches  are  tied  so  that  the  knot  falls  within  the 
peritoneal  cavity,  an  assistant  holds  two  fingers  back  of  the  uterus 
to  prevent  the  inclusion  of  a  loop  of  bowel.  The  patient  remains 
in  bed  three  weeks  and  avoids  violent  strains,  joks,  and  jars  for 
several  months  afterward. 

The  Baldy  operation^  utiKzes  the  round  ligament  in  an  in- 
genious manner  to  hold  and  support  the  uterus  in  an  anterior 
position.  A  hemostat  pierces  the  broad  ligament  from  behind 
under  the  ovarian  ligament  and  close  to  the  edge  of  the  uterus. 
The  forceps  seizes  the  round  ligament  about  an  inch  and  a 
half  to  two  inches  from  its  origin  at  the  cornu  and  pulls  it  through 
the  hole  in  the  broad  ligament.  The  same  is  done  on  the  other 
side.  The  loops  of  round  ligament  are  approximated  behind  the 
uterus  and  are  fastened  to  one  another  and  to  the  posterior  uterine 
wall  in  the  middle  Hne  at  about  the  junction  of  the  upper  and 
middle  third  of  the  corpus  uteri  with  celloidin  linen  thread.  If 
the  point  on  the  uterine  wall  is  properly  chosen,  it  is  impossible  to 
push  the  uterus  back  again  into  a  posterior  position  after  the  sutures 
are  tied.  This  operation  utilizes  the  strong  uterine  end  of  the  round 
ligaments,  which  play  like  a  rope  through  a  pulley,  the  latter  being 
represented  by  the  unyielding  ovarian  ligament.     I  have  used  this 

1  Olshaiisen  was  the  first  to  perform  a  modern  uterine  suspension.  Kelly  intro- 
duced it  in  America  after  a  visit  to  Olshausen's  clinic.  Sims,  Kaltenbach,  Koeberle, 
Schroeder,  Hennig,  and  Tait  had  previously  attempted  to  fasten  the  uterine  fundus  to 
the  anterior  abdominal  wall.  Boldt  and  Leopold,  in  1890,  passed  the  sutures  through 
the  uterine  fundus  instead  of  through  the  uterine  cornua  and  ovarian  ligaments,  as 
Olshausen  and  Kelly  originally  did. 

^  Out  of  more  than  700  operations  for  displacement,  I  have  done  it  about  600 
times. 

*  Baldy  has  employed  this  principle  for  about  eiglit  years,  but  has  modified  and 
improved  the  technic.  Webster  utilized  tlie  same  principle,  but  in  a  less  perfect 
manner,  not  joining  the  round  ligaments  behind  the  uterus. 


PREPARATION  FOR   ABDOMIXAL    OPERATIONS. 


919 


operation  in  an  increasing  number  of  cases  during  the  past  two 
years  and  like  it  better  the  more  I  see  of  it. 


Fig.  748. — The  Baldy  operation  :   Round  ligaments  caught  in  the  grip  of  a  hemostat 
and  pulled  back  through  the  broad  ligament. 


Fig.   749. — The    IJaldy  o]ieration  :    Round  ligaments   apinoximatcd   in  ilie  mid-line 
posteriorly  and  united  by  a  suture  of  linen  tlircad. 

The  Operative  Treatment  of  Diastasis  of  the  Recti  Muscles. — 

If  tlie  recti  muscles  gape  more  than  four  lingers'  breadth  after 
childbirth  and  if  they  afford  insufficient  support  to  the  abdominal 


920 


OBSTETRIC   OPERATIONS. 


wall,  the  patient  should  wear  an  abdominal  supporter,  should 
have  electricity  and  massage  applied  to  the  abdomen,  and  should 
be  put  through  a  course  of  Swedish  exercises.     If,   after  some 


Fig.  750. — The  Baldy  operation  :    Round  ligaments  joined. 


Fig-  75^- — The  Baldy  operation  :  Round  ligaments  joined  and  fastened  to  the  uterus. 


months  of  treatment,  the  abdominal  support  is  insufficient  and  if 
ptosis  of  the  abdominal  viscera  begins  to  be  manifest,  operative 
treatment  is  indicated. 

Webster  has  devised  an  operation  for  the  purpose  which  is 


PREPARATION  FOR   ABDOMINAL    OPERATIONS. 


921 


satisfactory.  Its  technic  is  as  follows:  A  long  incision  is  made 
through  the  skin  in  the  middle  line  of  the  abdomen,  beginning  well 
above  the  umbilicus  and  extending  to  the  symphysis.  The  fat, 
superficial  fascia,  and  skin  are  dissected  back  in  one  piece  until 


Fig.  752. — The  '•Storm"'  abdominal  binder. 


Fig.  753. — Webster's  operation 
for  diastasis  of  the  recti  muscles, 
modified.  The  sheaths  of  the  recti 
muscles  are  split  after  dissecting 
back  the  skin  and  subcutaneous  fat 
of  the  abdominal  wall. 


Fig.  754. — Webster's  operation  for 
diastasis  of  the  recti  muscles,  modified. 
Mattress  sutures  of  formalin  catgut  are 
inserted  through  the  outer  edges  of  the 
two  sheaths,  and  silkworm-gut  sutures  are 
passed  between  them,  through  the  skin, 
subcutaneous  fat,  and  outer  edges  of  the 
sheaths. 


both  recti  are  exposed.  The  anterior  sheaths  of  the  recti  are  split 
the  whole  length  of  the  wound.  The  muscles  are  loosened  by 
blunt  dissection,  the  outer  edges  of  each  sheath  are  joined  together 
in  the  middle  Une  by  interrupted  and  continuous  chromic  catgut 


922  OBSTETRIC   OPERATIONS. 

sutures,  so  that  the  intervening  tissues  are  tucked  into  the  abdominal 
cavity.  The  rest  of  the  wound  is  closed  and  dressed  as  is  any 
abdominal  section. 

Coccygectomy. — One  of  the  coccygeal  joints  is  frequently 
sprained  in  labor  and  the  patient  complains  of  pain  for  some  tim_e 
afterward,  but  the  vast  majority  of  cases  are  spontaneously 
cured  within  six  months.  If  after  that  time  pain  persists  so  severe 
that  the  patient  is  seriously  annoyed  by  it  and  if  a  physical  examina- 
tion demonstrates  a  rupture  of  a  coccygeal  joint,  anchylosis  of  the 
bone  in  a  straight  line,  or  caries  of  one  of  the  coccygeal  vertebrae, 
coccygectomy  is  indicated.^  The  technic  of  the  operation  is  as 
follows:  An  incision  is  made  through  the  skin  and  fat  over  the 
middle  of  the  bone,  from  above  the  two  tubercles  on  the  end  of 
the  sacrum  to  within  a  short  distance  of  the  tip  of  the  coccyx,  to 
keep  the  wound  as  far  from  the  anus  as  possible.  The  edges  of 
the  wound  are  retracted  with  forked  retractors.  The  coccyx  is 
severed  with  scissors  from  all  its  attachments,  except  its  junction 
with  the  sacrum.  A  Gigli  saw  is  slipped  under  the  coccyx,  care, 
being  taken  to  place  it  above  the  alae  of  the  first  coccygeal  vertebra. 
The  bone  is  sawed  off,  taking  the  extreme  tip  of  the  sacrum  with  it. 
The  wound  is  closed  with  interrupted  silkworm  gut  sutures,  which 
must  include  the  two  fibrous  bands  on  the  back  wall  of  the  rectum 
and  must  obhterate  all  dead  spaces.  The  wound  is  sealed  with  a 
collodion  dressing. 

1  It  is  necessary  to  exclude  hysterical  pains  in  the  coccyx,  rheumatism,  and  the 
reflex  coccygeal  pain  of  a  retrodisplaced  uterus. 


PART  VII. 
THE  NEW-BORN  INFANT. 


CHAPTER  1. 
Physiology  of  the  New-born  Infant. 

Respiration. — There  are  two  factors  which  explain  the  in- 
stitution of  respiration:  (i)  External  irritation,  the  result  of  a 
change  of  environment.  The  child  is  almost  instantaneously 
transformed  from  an  aquatic  to  a  terrestrial  animal,  passing  from 
a  liquid  medium,  with  a  temperature  of  99°  F.,  to  the  air,  with  a 
temperature  of  70°  F.,  the  shock  of  this  sudden  transition  causing 
a  reflex  action  of  all  the  muscles,  including  those  of  respiration. 
(2)  The  maternal  supply  of  oxygen  being  cut  off  from  the  fetal 
blood  as  the  placenta  is  separated  or  compressed,  there  is  an  ac- 
cumulation of  COj,  the  primary  action  of  which  is  that  of  a  stim- 
ulant to  the  respiratory  apparatus  and  to  the  brain-centers 
governing  respiration.  The  power  of  the  latter  factor  is  often 
shown  during  or  before  labor.  Should  anything  diminish  the 
supply  of  oxygen  to  the  fetal  blood,  such  as  pressure  upon  the 
cord,  there  is  an  immediate  effort  to  respire.  If  the  membranes 
are  unruptured,  liquor  amnii  is  sucked  into  the  lungs.  If  the 
head  is  in  the  vagina,  or  if  air  is  admitted  to  the  uterus  after  rup- 
ture of  the  membranes,  respiration  may  be  begun  long  before 
birth,  and  the  child  has  actually  been  heard  to  cry  aloud  u  ithin 
the  womb  {vagitiis  utcviims). 

The  rate  of  respiration  at  birth  is  44  to  the  minute,  sinking 
shortly  to  35. 

The  weight  at  birth  is  about  7  '^  pounds.  There  is  a  steady 
increase  of  about  i  Y^  pounds  each  month  before  and  i  pound 
after  the  fourth  month. 


WftlC.HT, 

Month. 

Pounds. 

I 

7-75 

2 

9-5 

3 

II 

4 

12.5 

5 

14 

6 

15 

Weight, 

ONTII. 

Pounds. 

7 

16 

8 

17 

9 

18 

10 

19 

II 

20 

12 

21 

92i 


924  THE   NEW-BORN  INFANT. 

There  is  normally  a  loss  of  5  ^  ounces,  on  the  average,  during 
the  first  two  to  five  days,  which  is  usually  made  up  by  the  end  of 
the  first  week.     Some  children,  however,  gain  steadily  from  birth. 

Digestion  is  accomplished  by  the  digestive  juices,  except  the 
diastatic  ferment  of  the  pancreas  and  of  the  salivary  glands.  It 
is  partially  dependent  upon  the  bacteria  normally  present  in  the 
alimentary  tract.  A  knowledge  of  the  capacity  of  the  stomach 
is  important  if  one  would  avoid  the  common  error  of  overfeed- 
ing a  new-born  infant. 

The  capacity  of  the  infant's  stomach  is,  on  the  average,  dur- 
ing the  first  week,  46  c.c.  (1.5  fl.  oz.)  ;  second  week,  78  c.c.  (2.5 
fl.  oz.)  ;  third  and  fourth  weeks,  85  c.c.  (nearly  3  fl.  oz.) ;  third 
month,  140  c.c.  (nearly  5  fl.  oz.)  ;  fifth  month,  260  c.c.  (about 
9  fl.  oz.)  ;   ninth  month,  375  c.c.  (12.5  fl.  oz.). 

The  greater  the  infant's  weight,  the  greater  the  gastric 
capacity.  One  one-hundredth  of  the  body-weight  plus  one 
gram  each  day  is  a  fairly  accurate  formula  for  the  expression  of 
gastric  capacity  in  the  new-born.  In  a  child  of  normal  weight 
the  capacity  should  be  one  ounce  at  birth  and  an  increase  of  one 
ounce  per  month  up  to  the  sixth  month,  after  which  it  is  some- 
what less  (Holt). 

The  Position  of  Stomach. — Its  axis  is  almost  longitudinal, 
which  in  part  explains  the  frequent  regurgitation  and  vomiting 
of  early  infancy.  It  is  placed  high  on  the  left  side  under  the 
false  ribs,  so  that  it  is  influenced  by  the  movement  of  the  float- 
ing ribs  in  respiration. 

Excretions. — The  urine  is  albuminous  for  the  first  few  weeks. 
The  quantity  is  difficult  to  estimate.  It  is  always  acid  in  reac- 
tion. The  specific  gravity  is  low,  1003—5.  -^  trace  of  sugar  is 
often  found  in  breast-fed  infants  and  in  those  fed  upon  an  arti- 
ficial food  containing  sugar  of  milk.  The  urine  is  voided  six  to 
twenty  times  in  twenty-four  hours.  It  does  not,  as  a  rule,  stain 
the  diapers,  and  the  mistake  may  thus  be  made  of  supposing 
none  to  have  been  voided. 

The  movements  from  the  bowels  consists  for  the  first  forty- 
eight  hours  of  meconium,  a  substance  greenish-black  in  color, 
and  consisting  mainly  of  bile-salts  and  coloring  matter.  Later, 
the  evacuations  become  light  yellow,  are  not  formed,  are  sour  in 
smell,  acid  in  reaction,  and  have  a  slightly  fecal  odor.  The  nor- 
mal frequency  of  evacuation  is  from  three  to  four  times  in  the 
twenty-four  hours. 

The  temperature  is  always  slightly  elevated  directly  after 
birth.  It  then  sinks  a  little  below  normal.  Its  subsequent  course 
is  marked  by  considerable  irregularity,  with  the  variations  usu- 
ally above  98°.  Comparatively  slight  causes  produce  high  tem- 
peratures. 


PHYSIOLOGY  OF   THE   NEW-BORN  INFANT. 


925 


The  eyesight  is  always  hypermetropic. 

The  pulse  beats  from  125  to  160  in  the  minute.  It  should  be 
counted  by  listening  to  the  beat  of  the  heart,  and  not  by  feeling 
the  pulse,  as  in  an  older  child  or  adult. 

The  blood  has  a  total  bulk  to  the  body-weight  of  8  per  cent; 
there  are  six  to  seven  millions  red  blood-corpuscles  to  the  cubic 
millimeter  ;  they  are  more  spherical  than  in  the  older  child,  and 
do  not  tend  to  form  rouleaux.  Shadow  corpuscles  are  abundant. 
White  blood-corpuscles  are  more  numerous,  viscid,  and  deliques- 
cent than  in  the  adult.     There  is  a  laree  amount  of  hemocrlobin 


Fig.  755- 


-The  circulation  in  the  young  embryo,  before  the  atrophy  of  the 
umbihcal  vesicle. 


at  birth  compared  with  the  mother's  blood — 120.2  percent,  in 
the  infant  and  93.8  per  cent,  in  the  mother.  At  thirty -six  to 
forty -eight  hours  after  birth  the  percentage  of  hemoglobin  is 
highest,  and  then  begins  to  diminish.  ^  The  ordinary  jaundice 
of  the  new-born  infant  is  due  to  the  superabundance  of  red  blood- 
corpuscles  which  arc  destroyed  in  the  liver,  giving  rise  to  an 
excess  of  bile-pigment.  It  is  reasonable  to  suppose  that  it  may 
also  be  in  part  hematogenic,  the  destruction  of  the  red  blood- 
corpuscles  setting  free  a  certain  amount  of  coloring  matter  in 
the  blood,  which  is  directly  absorbed  by  the  tissues. 
1  Cattaneo,  "  Diss.  Inaug.,"  Basel,  1892. 


926 


THE  NEW-BORN  INFANT. 


The  heart  exhibits  a  transition  from  the  fetal  to  the  infantile 
circulation  by  the  closure  of  the  foramen  ovale,  the  obliteration 
of  the  ductus  arteriosus  and  venosus,  the  obliteration  of  the 
hypogastric  arteries,  and  the  disappearance  of  the  Eustachian 
valve  (Figs.  755,  756). 

The  umbilical  cord,  after  twenty -four  hours,  shows  a  line  of 
demarcation  at  its  base.  There  is  then  a  necrosis  of  the  amniotic 
covering,  a  mummification  of  the  mucous  tissue,  and  a  destruc- 


Fig-  756- — The  circulation  in  the  mature  fetus  before  birth. 


tion  of  its  vessels.  The  cord  drops  off  about  the  fourth  day.  Its 
detachment  is  followed  by  the  retraction  of  the  granulating 
stump  within  the  umbilical  ring. 

Abnormalities  in  the  Physiology  of  Premature  Infants. — 

The  two  main  deviations  are  low  temperature — variations  below 
98° — and  inability  to  ingest  and  digest  food. 

The  management  of  premature  infants  consists  of  incubation 
and  gavage.      In  the  absence  of  a  specially  constructed  incubator. 


PHYSIOLOGY  OF   THE   NEW-BORN  EX  FA  NT. 


927 


such  as  that  represented  in  Figs.  757  and  758,  one  can  be  readily 
improvised  with  an  ordinary  infant's  bath-tub,  several  layers  of 
cotton-wool  or  lambs'  wool,  and  a  number  of  bottles  filled  with 
hot  water.  Gavage  is  the  regular  feeding  of  the  infant  with 
freshly  drawn  mother's  milk  through  a  small  soft  catheter  passed 
into  the  stomach  at  each  feeding.  A  more  convenient  and  quite 
as  efficient  a  plan  is  to  draw  the  mother's  milk  with  a  breast- 
pump  and  to  feed  it  to  the  child  through  a  medicine  dropper,  a 
few  drops  being  allowed  to  trickle  into  its  mouth  at  a  time.     The 


Fig.  757-  l''.^'-  7.vS. 

Figs.    757  and  758. — The   Kny-Scheerer  improved  incubator. 

intervals  between  feedings  should  be  an  hour  and  the  quantity 
administered  should  at  first  be  no  more  than  a  dram.  The  child 
should  not  be  bathed,  but  should  receive,  instead,  a  dail}-  rub 
with  warm  oil.  It  should  not  be  clothed,  but  should  be  buried 
in  wool  except  its  face.  A  diaper  should  be  put  under  but  not 
around  the  buttocks,  and  must  be  changed  often  enough  to  pre- 
vent chafing. 

The  mortality  of  this  treatment  has  so  much  improved  the 
chances  of  a  premature  infant  that  at  six  months,  according  to 
Tarnier's  statistics,  22  per   cent,  are  .saved  ;   at  seven  months,  38 


928  THE   NEW-BORN  INFANT. 

per  cent,  are  saved.  Charles,  ^  from  an  analysis  of  932  premature 
births,  found  that  at  six  months  10  per  cent,  were  saved  ;  at  six 
and  a  half,  20  per  cent.  ;  at  seven,  40  per  cent.  ;  at  seven  and  a 
half,  75  per  cent. 

Sclerema  is  a  disease  of  premature  infants,  seen  most  often 
in  lying-in  hospitals.  The  most  prominent  symptom  is  a  har- 
dening of  the  skin,  beginning  in  the  legs  and  spreading  over 
the  body,  usually  sparing  the  breast  and  abdomen.  Jaundice  or 
a  hemorrhagic  tendency  often  accompanies  it.  The  temperature 
is  very  low,  remaining  at  or  below  95°.  The  pathology  of  the 
disease  is  not  well  understood.  It  has  been  ascribed  to  edema. 
The  most  probable  explanation  is  that  the  large  excess  of 
stearin  and  palmitin  in  the  subcutaneous  fat  of  infants  solidifies 
when  the  temperature  falls  below  normal.  The  condition  is  a 
grave  one  and  is  likely  to  be  fatal.  The  treatment  consists  in 
incubation,  stimulation,  and  support. 

The  Management  of  the  New=born  Infant. — Clothing. — An 
infant  should  be  clothed  in  winter  as  follows  :  A  binder,  of. 
flannel  or  knit  wool,  twice  around  abdomen  ;  a  knit  shirt,  diaper, 
knit  shoes,  and  two  skirts,  the  first  flannel  (in  midsummer,  linen), 
and  finally  its  dress.  The  skirts  should  be  supported  from  the 
shoulders  by  sleeves  or  tapes.  Each  skirt  should  be  made  with 
a  body,  and  not  with  a  band.  A  knit  jacket  may  be  worn  over 
the  dress.  A  light  flannel  shawl  or  cap  is  desirable  to  protect 
the  child's  head  from  cold,  when  it  is  lifted  from  its  crib  or 
carried  to  another  room. 

As  an  infant  urinates  frequently,  the  diapers  are  changed 
about  twenty  to  twenty-four  times  a  day.  The  buttocks  should 
be  carefully  dried  and  powdered  with  compound  talcum,  borated 
talcum,  oxid  of  zinc  and  lycopodium,  or  rice-flour  powder. 

Feeding. — Hiiinan  Milk. — The  secretion  is  established  at  the 
end  of  forty-eight  hours.  It  derives  its  origin  from  an  over- 
growth of  epithelial  cells  lining  the  ducts  of  the  mammary  glands, 
their  infiltration  with  fat,  and  subsequent  rupture.  The  specific 
gravity  is  1024-35,  the  reaction  alkaline.  Each  minute  fat- 
globule  is  surrounded  by  a  pellicle  of  serum-albumin. 

Chemical  Constitution. 

Meigs.  Vogel.  Gautrelet. 

Water      87.163  89.5                 88.1 

Fat 4.283  3.5                    4-0 

Casein 1. 046  2.0                    2.2 

Sugar 7- 407  4-8                   6.2 

Ash o.ioi  0.17                 0.5 

1  "  Viabilite  des  nouveau  nes  cl  terme  at  avant  terme,"  "Archives  d'Obstet.," 
1893,  p.  412. 


PHYSIOLOGY  OF   THE   KEW-BORN  IXFANT.  929 

Fat. — This  constituent  of  human  milk  is  subject  to  wide 
variations  in  quantity  under  the  influence  of  diet  and  general 
health.  Under  normal  conditions,  however,  it  stands  quite  con- 
stantly at  four  per  cent. 

Proteids  of  Milk. — The  proteids  of  milk  are  casein  and  lact- 
albumin. 

CasciJi. — Casein  is,  strictly  speaking,  the  curd  of  milk,  formed 
by  a  digestive  ferment  acting  upon  "  caseinogen,"  a  proteid 
analogous  to  fibrinogen,  myosinogen.  Caseinogen  is  a  peculiar 
substance,  neither  an  alkali-albumin  nor  a  globulin,  but  occupy- 
ing a  distinct  position  among  proteids. 

Lactalbinnin. — A  proteid  resembling  closely  serum-albumin, 
but  somewhat  different  from  it.  It  is  present  in  small  quantities 
— one-half  of  one  per  cent.  When  the  milk  is  curdled,  a  new 
proteid  appears  in  whey,  called  "  whey -proteid,"  which  is  soluble 
and  non-coagulable  by  heat. 

The  sugar  is  lactose  ;  it  is  not  strong  in  sweetening  properties. 

Tlie  ash  of  human  milk  is  made  up  mainly  of  potassium, 
sodium,  calcium,  and  phosphoric  acid. 

The  quantity  of  milk  at  each  nursing  is  difficult  to  determine. 
It  maybe  estimated  by:  (i)  The  infant's  gain  in  weight  after 
each  feeding.  This  is  not  constant,  varying  from  three  to  six 
ounces.  (2j  The  capacity  of  the  infant's  stomach.  (3)  The 
quantity  secreted  in  twenty -four  hours,  divided  by  the  number  of 
nursings.  At  the  end  of  the  seventh  day  the  quantity  in  twenty- 
four  hours  is  fourteen  ounces  ;  at  the  end  of  the  fourth  week, 
two  pints. 

If  the  mother  can  not  nurse  her  child,  the  best  substitute, 
theoretically,  is  a  wet-nurse. 

The  selection  of  a  wet=nurse  should  be  governed  by  the  fol- 
lowing considerations  : 

She  should  have  milk  of  good  qualitj',  whxch.  \s  best  ]v\dg&d 
by  the  appearance  of  her  own  child. 

She  should,  preferably,  be  a  multipara,  and  of  suitable  age; 
her  child  should  be,  approximately,  the  same  age  as  the  one  to 
be  nursed  ;  her  nipples  should  be  well  shaped  ;  and  it  is  an  ad- 
vantage to  hav^e  made  a  chemical  analysis  of  her  milk. 

She  should  have  an  equable  disposition  and  an  absence  of 
disagreeable  qualities. 

Above  all,  she  should  not  liave  syphilis.  As  a  matter  of  fact, 
wet-nurses  are  so  inconvenient  and  disagreeable  in  the  average 
.household,  and  the  results  of  artificial  feeding  have  so  markedly 
improved,  that  the  vast  majority  of  children  who  are  not  nursed 
by  their  mothers  arc  raised  on  the  bottle. 

Artificial  Feeding. — Asses'  and  goats'  milk  are  more  like 
59 


930  THE   NEW-BORN  INFANT. 

human  milk  than  is  cows'  milk,  but,  as  they  are  not  conveniently- 
procurable,  the  last  is  universally  used.  To  appreciate  why  so 
large  a  proportion  of  artificially  fed  children  die  annually,  particu- 
larly in  the  hot  summer  months,  it  is  sufficient  to  glance  at  the 
differences  between  cows'  and  human  milk.  ^  The  most  important 
differences  may  be  briefly  tabulated  as  follows  : 

Gross  Appearances. — Cows' — a  dead  white  in  color,  and 
opaque.  Human — often  yellow ;  sometimes  bluish.  More 
translucent. 

Reaction. — Cows'^acid.      Human — alkaline. 

Specific  Gravity. — Cows' — 1030—35.      Human — 1024-35. 

Curd  Coniparisoi. — The  coagulum  produced  by  a  digesting 
ferment,  as  rennet,  is  dense,  tough,  and  digested  with  difficulty 
in  cows'  milk  ;  light,  flocculent,  and  easily  digested  in  human 
milk. 

This  difference  is  due  merely  to  the  larger  quantity  of  case- 
inogen  in  cows'  milk,  and  to  the  acidity.  Dilute  cows'  milk  and 
make  it  alkaline,  and  the  curd,  on  the  addition  of  rennet,  is  as 
light  and  flocculent  as  in  human  milk. 

Chejnical  Comparison. — Cows'  milk  contains  more  casein  and 
less  sugar. 

Comparative  Analyses.  .    . 

Meigs.  \'ogel.        Lehman.  Gautrelet. 

Human.    Cows'.  Human.  Cows'.  Human.    Cows'. 

Water 87.16  87.1  89.5  87.5  88.1  85.61 

Fat 4.28  4.20              3.5                3.5  4.0  4.0 

Casein 1. 04  3.25              2.0                3.5  2.2  3.5 

Sugar 7.40  5.0                4.8                4.8  6.2  6.0 

Ash o.io  0.52              0.17              0.75  0.5  0.85 

Histological  Comparison. — It  is  asserted  that  the  albuminous 
envelope  surrounding  the  fat-globules  is  thicker  and  tougher  in 
cows'  milk.  Colostrum-corpuscles  are  found  in  human  milk, 
normally,  up  to  the  eighth  or  tenth  day.  They  return  under 
influences  interfering  with  lactation,  as  heretofore  described. 

Bacteriological  Comparison. — Human  milk  comes  from  the 
breast  practically  sterile.  Cows'  milk  in  cities,  particularly  in 
hot  weather,  after  twenty-four  hours,  swarms  with  all  kinds  of 
pathogenic  and  non-pathogenic  micro-organisms  and  their  pro- 
ducts, some  of  which  are  virulent  toxins. 

Quantitative  Comparison. — Human  milk  is  furnished  in  quan- 

1  According  to  official  statements  relating  to  the  Russian  foundling  hospitals  at 
St.  Petersburg  and  Moscow,  about  1,000,000  newly  born  children  have  been  given 
over  to  them  during  the  last  hundred  years,  most  of  them  illegitimate.  Of  this  large 
number,  nearly  800,000  have  died  in  the  first  months  or  first  years  of  their  existence. 
A  well-known  authority  on  statistics  satirically  calls  it  "  chronischer  Kindermord 
auf  Staatskosten "   ("chronic  infanticide  at  the  cost  of  the  State"). 


PHYSIOLOGY  OF  THE  NEW-BORN  INFANT.  93  I 

tity   and    at    intervals    suitable   for   the   infant.      Artificially   fed 
children  are  often  overfed. 

Preparation  of  an  Artificial  Food. — In  making  an  artificial  food 
with  cows'  milk  as  a  basis,  three  factors  must  be  borne  in  mind  : 
the  quantity  required,  the  differences  in  chemical  composition 
and  reaction,  and  the  microbic  infection.  The  first  may  be  regu- 
lated by  the  following  table,  based  upon  a  study  of  the  capacity 
of  the  infantile  stomach  : 


Number  of 
Feedings 
IN  Twenty- 
four  Hours. 


Amount  of  Food      Total  Amount 
Age.  Interval.        ,'^^"i'!!!X^,  at  Each  in  Twenty- 

Feeding,  four  Hours. 


First  week 2  hrs.  10  i  oz.  10        ozs. 

Second  to  fourth  week  ,    ,  2  "  9  l^  ozs.  13^  " 

Second  to  third  month  .    .  3  "  6  3  "  18  " 

Third  to  fourth  month    .    .  3  "  6  4  "  24  " 

Fourth  to  fifth  month      .    .  3  "  6  4-4/^  "  24-27    " 

Sixth  month 3  "  6  5  "  30  " 

Eighth  month 3  "  6  6  "  36  " 

Tenth  month 3  "  5  8  "  40  " 

The  difference  in  chemical  composition  and  reaction  may  be 
removed  by  diluting  the  whole  to  reduce  the  casein,  adding 
cream  and  milk-sugar,  and  making  the  mixture  alkaline.  The 
microbic  infection  of  cows'  milk  may  be  obviated  by  pasteuriza- 
tion. ^      The  following  formula  accomplishes  these  purposes  : 

Milk  for  one  bottle 4  drams 

Water  (boiled) 5      " 

Cream i  dram 

Lime-water I      " 

Milk-sugar 20  grains. 

To  pasteurize  the  milk,  six  bottles  should  be  made  up  for 
the  ensuing  twelve  hours. 

Stopper  the  mouth  of  each  bottle  with  dry,  baked  cotton  ; 
put  them  in  an  Arnold's  pasteurizer;  raise  temperature  to  170°. 
Put  on  hood  and  let  stand  off  the  stove  for  thirty  minutes. 

Set  aside  to  cool  and  then  put  in  a  refrigerator. 

Apply  a  plain  rubber  nipple  to  the  bottle  before  use. 

Warm  it  to  blood  heat  in  a  warming  cup  before  giving  it  to 
the  child. 

Cleansing. — The  infant  should  receive  a  daily  bath  in  the 
middle  of  the  da\-  in  the  warmest  part  of  the  room.  The  tem- 
perature of  the  water  should  be  not  much  over  90°.  The 
nurse,    whose    hands    are    commonh'   insensible    to    hot    water, 

^  By  this  term  is  meant  the  subjection  of  the  milk  to  a  temperature  of  167°-! 75°, 
which  sterilizes  it  but  does  not  impair  its  nutritive  value  as  steam  sterilization  or 
boiling  does. 


932  THE   NEW-BORN  INFANT. 

should  be  required  to  use  a  bath  thermometer.  Castile-soap 
and  a  soft  sponge  should  be  used,  and  care  must  be  exercised 
not  to  irritate  the  eyes.  For  the  first  week  the  child  should  be 
simply  sponged  on  the  nurse's  lap.  After  that,  if  it  is  strong 
and  vigorous,  it  may  be  immersed  in  the  tub. 

Airing. — In  summer  the  baby  may  be  taken  out  after  the 
second  month  ;  in  winter  after  the  third  month,  for  a  short  time, 
in  the  warmest  part  of  the  day. 

The  resting  place  should  be  a  crib,  and  not  a  cradle. 


CHAPTER  II. 

Pathologfy  of  the  New-bom  Infant. 
INJURIES  TO  THE  INFANT  DURING  LABOR. 

[Classified  Accorditig  to  the  Seat  of  Injury.'^, 

The  first  four  weeks  of  life  show  the  highest  mortahty.  About 
lo  per  cent,  of  the  children  bom  die  of  immaturity,  asphyxia, 
atelectasis,  malformations,  injuries  and  infection.^ 

Brain. — Injury  to  the  brain  is  most  frequently  the  result  of 
the  faulty  use  of  forceps  or  of  the  violent  extraction  of  the  after- 
coming  head.  It  may  be  a  meningeal  hemorrhage,  varying 
in  extent  from  the  rupture  of  a  small  vessel  and  a  slight  extrava- 
sation of  blood  to  the  laceration  of  the  longitudinal  sinus  and  a 
fatal  intracranial  hemorrhage.  If  less  in  degree,  the  child  may 
live  to  adult  age,  but  is  apt  to  show  impaired  physical  or  mental 
development.  The  brain-substance  may  be  crushed.  Injuries 
may  be  inflicted  upon  the  brain  not  so  grave,  but  affecting  intel- 
lectual or  physical  centers,  and  the  subsequent  mental  or  physical 
development  of  the  individual.  There  may  be  simply  com- 
pression of  the  brain,  causing  perhaps  asphyxia. 

Persistent  priapism  may  be  seen  occasionally,  as  a  result  of 
injury  to  the  brain  or  cord.^ 

Peripheral  Nerves. — The  facial  and  brachial  plexuses  are  the 
peripheral  nerves  most  frequently  damaged.  The  majority  of 
cases  of  facial  hemiplegia  are  due  to  the  faulty  use  of  forceps 

1  Based  on  the  statistics  of  i  ,439,000  births  (Snow,  "Archives  of  Pediatrics," 
September,  1903). 

2  In  one  of  my  cases  priapism  persisted  for  two  weeks,  to  the  dismay  of  the 
mother,  who  feared  it  would  be  permanent. 


INJURIES    TO    THE   INFANT  DURING  LABOR. 


933 


Recovery  may  be  expected,  usually  in  the  course  of  a  week. 
Should  this  fail  to  occur,  the  faradic  current  may  be  used  with 
advantage.  Facial  palsies  at  birth  are  usually  unilateral  and 
transitory  ;  they  may,  however,  be  bilateral  and  permanent.  The 
brachial  palsies  result  from  unskilled  attempts  at  extracting  the 
shoulders  and  arms,  and  are  likely  to  be  permanent. 

Skull. — Spoon=shaped  depressions  of  parietal  or  frontal  bones 
may  be  caused  by  a  prominent  promontory  or  by  forceps.  It 
has  been  suggested  to  elevate  the  depression  by  pneumatic  trac- 
tion or  by  trephining. 

Fractures,  if  compound,  require  an  aseptic  dressing.  Re- 
covery, even  from  so  grave  an  injury,  sometimes  occurs. 


Fig-   759- — Spoon-shaped  depression  and  fracture  of  a  parietal  bone  (Winckel), 


Fig.   760. — Formation  of  caput  succedaneum  :  o.  e..  External  os  ;  b^  bladder; 
u,  urethra  ;   t',  vagina. 


Distortion  of  the  head  is  very  common,  almost  constant.  Its 
variations  in  form  are  the  result  of  the  different  presentations  and 
positions.  The  deformity,  even  though  very  marked,  disappears 
within  the  first  three  days  (Figs.  761-766). 


934 


THE   KEW-BORX  IXFAXT. 


Fig.  761. — The  undistorted  head  of  a 
breech  presentation  (SchroederJ, 


Fig.     762. — Right    occipito-posterior 
position  of  the  vertex  (Schroeder). 


Fig.  763. — Normal  vertex  (Schroeder). 


Fig.    764. — Outline  of  head  after  de- 
liver}-, the  brow  presenting  (Budin). 


Fig.  765. — Brow  presentation. 
(Schroeder). 


Fig.  766. — Face  presentation 
(Schroeder). 


IXJCRIES    TO    THE   JXFAXT  DCRLXG   LABOR. 


935 


Scalp. — Caput  Succedaneum. — A  serous  infiltration  of  that 
portion  of  the  presenting  part  corresponding  to  the  external  os. 
It  disappears  in  tAvo  or  three  days,  and  requires  no  treatment. 

Cephalhematoma  is  a  more  important  condition,  and  is  to  be 
distinguished  from  a  caput  succedaneum.  It  occurs  about  once  in 
two  hundred  cases.  Usually  two  or  three  da}'s  after  birth  a  swell- 
ing develops,  rapidly  increasing  in  size,  possessing  the  physical 
signs  of  a  cystic  tumor,  distinctly  confined  by  the  boundaries  of 
one  of  the  cranial  bones.  It  may  be  bilateral.  It  may  occupy 
the  parietal  and  the  occipital  bones,  and  it  may  possibly  develop 


Fig.  767. — Cephalhematoma. 


Fig.   76S. — Double  cephalhematoma. 


Fig.    7oy. — Longitudinal  section  through  a  cephalhematoma:    a.  Dura  mater; 
^.cranium;  «r,  pericranium  ;   c' ,c' ,  beginning  hyperostosis  ;  <?,  scalp  (Davis). 


before  birth.  It  is  due  to  a  subpericranial  hemorrhage,  which 
lifts  the  pericranium  from  the  bone,  irritates  it,  and  stimulates  it 
to  bone-production,  thus  giving  rise  to  a  bony  sensation  at  the 
lifted  edges  of  the  pericranium,  and  later  to  a  peculiar  crackling 
or  crepitus  over  the  surface  of  the  tumor,  due  to  the  movement 
of  the  thin  bone-plates  on  one  another.      Xon-intcrferencc  is  the 


936 


THE   NEW-BORN  INFANT. 


treatment,  except  when  the  hemorrhage  is  excessive  or  suppura- 
tion occurs.  The  former  may  be  controlled  by  pressure  and 
cold  ;  the  latter  requires  incision  and  drainage,  with  strict  asepsis. 
In  spite  of  the  greatest  care,  septic  meningitis  may  develop. 

Contused  and  lacerated  wounds,  usually  the  result  of  a 
forceps  operation,  are  to  be  treated  on  general  surgical  prin- 
ciples. 

Sloughs. — The  vitality  of  the  scalp  may  be  destroyed  by  for- 
ceps or  by  prolonged  pressure  from  the  pelvic  bones,  and  sloughs 
may  appear  in  the  first  few  days  after  birth.      They  require  the 

ordinary  surgical  treatment 
for  the  same  condition  any- 
where on  the  body. 

Face. — A  caput  succe- 
daneum  may  occupy  the 
face  if  it  presented  in  labor. 
The  eyes  and  the  mouth 
may  be  injured  by  careless 
examinations  or  by  violent 
extraction  of  the  after-com- 
ing head.  The  former  may 
be  injured  by  the  forceps. 
The  globes  may  be  luxated 
to  complete  exophthalmos ; 
the  recti  muscles  may  be 
permanently  paralyzed; 
there  may  be  subconjunc- 
tival or  palpebral  eechy- 
moses,  edema  of  the  lids,, 
and  temporary  ptosis  ;  frac- 
ture in  the  roof  of  the 
orbit ;  exudation  of  blood 
into  the  anterior  chamber. 
The  cheeks,  temples,  and 
forehead  may  be  bruised, 
crushed,  or  cut  by  forceps. 
Hematomata  may  develop- 
in  the  cheeks  within  twenty-four  hours  of  birth.  The  blood- 
tumors  should  be  let  alone,  as  in  the  case  of  a  cephalhematoma. 
Neck. — There  may  be  injury  and  thrombosis  of  the  neck- 
muscles,  with  reactive  inflammation,  most  frequently  of  the 
sternocleidomastoid,  with  the  development  of  torticollis.  This 
sort  of  wry-neck  usually  recovers  without  treatment. 

Fracture,  Dislocation,  or  Decapitation. — The  author  has  been 
told  the  details  by  eye-witnesses  of  three  cases  in  which  the  head 
was  pulled  off  after  version.     In  each  instance  Cesarean  section 


Fig.  770. — Child  in  face  presentation. 


INJURIES    TO    THE   INEANT  DURING  TAB  OR.  937 

was  done  to  extract  the  head.  The  women  all  died.  Crani- 
otomy should  obviously  have  been  the  operation  for  the  extrac- 
tion of  the  head. 

There  is  occasionally  injury  to  the  cervical  spine  and  to  the 
larynx  and  trachea,  in  consequence  of  the  excessive  twisting  of 
the  neck  that  occurs  when  the  occiput  turns  forward  from  a 
posterior  position  and  the  shoulders  do  not  follow  the  movement 
of  the  head. 

Limbs. — Fractures,  which  are  usually  a  separation  of  diaph- 
ysis  and  epiphysis,  require,  in  the  case  of  the  lower  extremities, 
surgical  fixation,  extension,  and  a  plaster  bandage.  In  the  case 
of  the  arms,  fixation  in  the  Velpeau  position  by  a  jacket  with 
only  one  arm-hole,  for  the  sound  arm.  Union  is  prompt.  Frac- 
tures are  usually  the  result  of  faulty  management  on  the  physi- 
cian's part,  but   they  may  be    spontaneous.       Avulsion   of   the 


Fig.    771. — Visceral  hemorrhages  into  the  kidney  (author's  case). 

limbs  sometimes  occurs  in  efforts  to  extract  a  premature  or 
macerated  fetus. 

In  a  case  admitted  to  the  University  Maternity,  both  arms  of 
a  well-developed  infant  were  pulled  off  in  an  attempt  at  version; 
the  uterus  was  ruptured  and  two  feet  of  ileum  were  pulled  loose 
from  the  mesentery. 

Trunk. — Perforations  of  the  groin  and  perineum  may  be  due 
to  the  use  of  a  blunt  hook  or  a  forceps  applied  to  the  breech. 
There  may  be  rupture  of  some  important  viscus,  like  the  spleen, 
liver,  or  lungs,  with  fatal  hemorrhage  into  the  peritoneal  or 
pleural  cavities,  especially  in  syphilitic  children  ;  or  visceral 
hemorrhage  may  occur,  as  in  the  kidney,  without  actual  rupture, 
but  to  a  sufficient  degree  to  abrosjatc  the  functions  of  the  ortran. 


938 


THE   NEW-BORN  INFANT. 


Fracture  of  the  clavicle  in  extracting  the  after-coming  head  may- 
result  in  the  puncture  of  the  lung  by  the  broken  end  of  the  bone 
and  in  fatal  emphysema.     The  kidney,  spleen,  and  liver  have 

been  ruptured  in  attempts  to 
extract  the  breech.  Subcapsular 
hemorrhages  in  these  organs  are 
observed  quite  frequently.  In 
the  pleura  there  are  often  ecchy- 
motic  spots  in  asphyxiated  chil- 
dren, with  minute  but  multiple 
extravasations  in  lungs  and  brain. 
The  pleura  may  be  lacerated, 
with  a  hematothorax  as  the  re- 
sult.^ The  body  may  remain 
distorted  for  some  time  as  the 
result  of  a  face  presentation,  and 
there  may  be  ecchymoses  upon  the  body  if  there  is  a  presenta- 
tion of  the  trunk. 


Fig.  772. — Child  born  in  face  presen 
tation  (Schroeder). 


F'&-  773- — -Back  presentation. 
Disposition  of  the  serosanguineous 
ecchymosis  (Budin). 


Fig.  774. — Fetus  after  a  presentation  of 
the  back,  shoulder,  and  elbow.  Disposition 
of  serosanguineous  ecchymosis  (Budin). 


Bowel. — The  large  bowel  may  rupture  from  preexisting 
ulceration  or  necrosis,  usually  at  the  sigmoid  or  other  flexures. 

1  "  Ein  Fall  von  traumatischen  Hematothorax  beim  Neugeborenen,"  "  Z.  f. 
G.  u.  G.,''  Bd.  XXX,  I  und  2;  Gebhard,  p.  402.  There  was  a  rupture  of  an  inter- 
costal vein  and  of  the  pleura  in  attempts  to  extract  a  breech  and  trunk. 


IXJURIES    TO    THE    LXFANT  DURING  LABOR.  939 

Asphyxia. — Asphyxia  of  the  new-born  child  results  in  con- 
sequence of  an  insufficient  supply  of  oxygen  to  the  blood.  To 
understand  its  causes  it  is  necessary  to  review  the 

Physiology  of  the  Institution  of  Respiration. — The  sudden 
changes  in  the  environment  of  the  fetus  (from  a  liquid  medium 
at  99°  to  the  air  at  70°)  produces  an  exaggerated  stimulation  of 
all  the  muscles  to  reflex  action,  including  the  muscles  of  respira- 
tion. Placental  respiration  is,  moreover,  abolished,  and  the 
accumulated  CO^  primarily  stimulates,  but  finally  paralyzes,  the 
respiratory  center. 

The  causes  of  asphyxia  are  : 

First,  intra-uterine.      Under  this  head  come — 

Fetal  inspiration. 

Any  interference  with  placental  respiration,  paralyzing  the 
brain-centers,  as  premature  detachment  of  placenta ;  coiling, 
compression,  or  prolapse  of  the  cord  ;  diminution  of  the  caliber 
of  the  umbilical  vessels,  as  from  syphilitic  periphlebitis  ;  excess- 
ive and  prolonged  uterine  contraction. 

Prolonged  pressure  on  the  fetal  brain  by  the  pelvis  or  by  for- 
ceps, paralyzing  the  brain-centers. 

Grave  systemic  diseases  of  the  mother,  and  accidents,  includ- 
ing hemorrhage,  uterine  or  pulmonary. 

Anomalies  or  diseases  of  the  fetus,  preventing  the  entrance  of 
air  into  the  respiratory  tract,  or  preventing  the  proper  distribu- 
tion of  blood  from  right  ventricle  to  the  lungs,  as  a  patulous  fora- 
men ovale  or  atresia  of  the  pulmonary  arter)^ 

Second,  extra-uterine  causes,  as — 

Placing  the  infant  after  birth  in  a  position  unfavorable  for 
respiration. 

Precipitate  labor. 

Interference  with  the  access  of  air  to  respiratory  passages,  as 
by  a  caul,  unruptured  membranes,  or  maternal  discharges. 

Asphyxia  neonatorum  is  divided  into  two  stages  : 

1.  Asphyxia  Livida. — In  this  stage  there  is  an  accumula- 
tion of  CO^  in  the  blood,  yet  the  circulation  continues  and  the 
reflexes  are  preserved.     The  prognosis  of  this  stage  is  favorable. 

2.  Asphyxia  Pallida. — This  is  an  advanced  stage  of  the  for- 
mer, characterized  by  weakness  of  the  heart,  slowing  of  its  pulsa- 
tions, and  the  abolition  of  the  reflexes.  The  prognosis  of  this 
stage  is  naturally  unfaxorable. 

Treatment. — If  possible,  asphy.xia  should  be  prevented  by 
removing  the  possible  causes  during  labor.  The  treatment  of 
the  condition  after  labor  consi.sts  of: 

1.  Extraction  of  mucus  from  the  throat  and  fauces  by  hold- 
ing the  child  by  the  feet  and  cleaning  the  mouth  with  a  finger. 

2.  The    application    of   exaggerated    stimuli    to    respiration, 


940 


THE   NEW-BO  RAT  INFANT. 


as  slapping  of  the  buttocks,  vigorous  rubbing  of  the  back  and 
chest ;  immersing  the  body  in  warm  water,  and  pouring  ice-water 
on  the  epigastrium  ;  applying  electricity,  if  practicable,  preferably 
in  the  shape  of  a  faradic  current,  one  pole  being  placed  on  the 
epigastrium  and  the  other  applied  on  the  sternum,  flanks,  and 
thighs.  The  electric  brush  is  most  efficacious.  In  the  pallid 
variety  only  the  most  powerful  of  these  stimuli  are  useful, 

3.  Artificial  respiration  is  induced  by  one  or  all  of  several 
methods. 

Sylvester's  is  not  to  be  recommended  because  the  pectoral 
muscles  of  the  infant  are  too  weak  to  inflate  the  chest  when 
pulled  upon  by  the  manipulation  of  the  arms. 


Fig.   775. — Schultze's  method  of  artificial  .respiration  :  A,  Inspiration  ;  B,  expiration. 


Marshall  Hall's  method,  modified  to  suit  the  requirements  of 
the  new-born  infant  by  suspending  it  in  a  towel,  and  thus  rolling 
it  from  side  to  side,  is  sometimes  useful. 

Byrd's  method,  flexing  and  extending  the  trunk,  and  holding 
the  child  upside  down  so  that  mucus  may  run  out  of  its  throat, 
is  efficient. 

Schultze's  method  is  one  of  the  best.  The  infant  should  be 
wrapped  in  a  towel  to  protect  it  from  being  chilled,  should  be  held 
as  shown  in  figure  775,  and  should  be  swung  between  the  physi- 
cian's knees  and  over  his  shoulder ;  after  practising  the  swinging 
movements  fifteen  to  twenty  times,  the  child  should  be  immersed 
for  a  few  seconds  in  warm  water  to  raise  its  temperature,  when 
the  movements  may  be  repeated. 

Mouth-to-mouth   insufflation   ranks  with   Schultze's  method^ 


DISEASES    OF   THE   AEW-BORN  EVEAA'T.  94 1 

or  is  superior  to  it.  The  exit  of  air  from  the  lungs  should  be 
facihtated  by  placing  the  infant's  neck  over  a  mug  or  cup  with 
the  head  extended,  and  after  inflating  the  lungs  flexing  the  head 
and  compressing  the  chest.  The  nose  should  not  be  held  to 
prevent  the  escape  of  air,  as  is  sometimes  advised.  The  physi- 
cian draws  a  full  breath  and  through  a  clean  towel  spread  over 
the  child's  face  blows  the  first  part  of  the  expired  air  into  the 
child's  mouth.  The  open  nostrils  serve  as  safety-valves.  The 
air-vesicles  of  the  lungs  are  not  so  likely  to  be  damaged. 

Catheterization  of  the  larynx  with  a  soft  catheter  and  direct 
inflation  of  the  lungs  is  only  advisable  if  there  is  tumefaction  of 
the  neck  or  some  other  mechanical  interference  with  the  entrance 
of  air  into  the  larynx.  Great  care  must  be  exercised  not  to 
injure  the  posterior  wall  of  the  trachea  nor  to  catheterize  the 
esophagus. 

As  a  last  resort,  tracheotomy  and  catheterization  through  the 
wound  may  be  required.  It  is  only  required  in  most  exceptional 
cases.  ^ 

Risks  Attending  Artificial  Respiration. — Injuries,  as  apo- 
plexies ;  Schultze's  method  may  injure  the  spine  ;  hemorrhagic 
effusions  in  the  pleurae  and  lungs  ;  rupture  of  the  air-vesicles  in 
insufflation  ;  the  trachea  and  larynx  may  be  injured  ;  the  lung 
may  be  punctured  if  the  clavicle  is  broken. 

After=treatment  of  Asphyxia  Neonatorum. — A  child  deeply 
asphyxiated  and  revived  with  difficulty  will,  more  likely  than 
not,  die  within  forty-eight  hours  of  birth.  It  should  be  carefully 
watched,  therefore,  for  at  least  two  days,  in  order  to  detect  rapid 
respiration,  feeble  heart-action,  and  evidence  of  intracranial  dis- 
turbance. It  is  a  good  practice  to  administer  routinely  to  such 
children  five  drops  of  brandy  and  a  drop  of  tincture  of  digitalis 
in  hot  water,  every  four  or  everj^  two  hours,  to  keep  them 
swathed  in  cotton-wool,  and  possibly  to  surround  them  with 
hot-water  bottles  or  bags,  if  their  vitality  is  low. 


DISEASES  OF  THE  NEW-BORN  INFANT. 

Diseases  of  the  Lungs. — Atelectasis. — The  causes  are  not 
known.  Sometimes  it  may  be  due  to  obstruction  of  the  air- 
passages,  as  by  an  enlarged  thymus,  a  clot  of  blood,  curd  of 
milk,  etc. 

The  diagnosis  is  usually  not  made  during  life.  Dullness  on 
percussion  might  be  detected  on  one  side  if  the  atelectasis  were 

1  I  was  obliged  to  resort  to  this  treatment  in  a  case  of  face  presentation  with 
such  distortion  of  the  neck  that  mouth-to-mouth  insulllation  and  catheterization  of  the 
larynx  were  impossible.  The  child  was  kept  alive  for  an  hour,  but  would  make  no 
attempt  at  respiration. 


942  THE  NEW-BORN  INFANT. 

unilateral.      The  respiration  is  accelerated  and  imperfect.      There 
is  an  absence  of  fever.      The  symptoms  are  present  at  birth. 

Pathological  Anatomy. — One  lung  is  found  shriveled  up,  is 
not  crepitant,  and  sinks  when  placed  in  water. 

The  prognosis  is  necessarily  grave. 

Treatment. — If  the  diagnosis  is  made,  gentle  insufflation  of 
the  lung  with  a  catheter  might  be  attempted. 

Syphilis  of  the  Lung. — The  diagnosis  may  be  made  by  a  his- 
tory of  syphilis  in  the  parents,  by  the  signs  of  fetal  syphilis,, 
together  with  the  cyanosis  and  physical  signs  of  pneumonia. 
The  temperature  is  very  low,  suggesting  the  use  of  an  incu- 
bator. Treatment,  however,  is  of  no  avail,  the  child  usually 
dying  within  twenty-four  to  thirty-six  hours. 

Pathological  Anatomy. — An  enormous  overgrowth  of  connec- 
tive tissue  is  found,  compressing  the  blood-vessels  and  diminish- 
ing the  capacity  of  the  air-vesicles.  As  some  air  has  entered 
the  lung,  a  cut-off  portion  never  sinks,  but  does  not  float 
buoyantly.  The  "white  pneumonia"  of  syphilitic  infants  is 
rare.  It  is  the  result  of  proliferation,  desquamation,  and  fatty 
degeneration  of  the  epithelial  cells  in  the  lungs,  giving  the  latter 
a  white  appearance,  and  distending  them  so  that  the  thoracic 
cavity  is  well  filled  out  and  the  lungs  bear  the  imprint  of  the 
ribs.      Respiration  is  impossible. 

Septic  infection  of  the  lungs  is  common.  It  is  the  result  of  in- 
spiration of  septic  matter  from  the  vagina  or  from  the  decomposi- 
tion of  inspired  blood-clots  or  vaginal  discharges. 

Tuberculosis  may  be  caused  by  mouth-to-mouth  insufflation 
on  the  part  of  a  tuberculous  person. 

Pneumonia  of  the  new-born  is  usually  caused  by  the  inspiration 
of  maternal  discharges,  resulting  from  intra-uterine  respiratory 
efforts  when  asphyxia  is  threatened.  The  result  is  usually  an  in- 
fection of  the  lungs,  septic  pneumonitis,  and  a  general  blood  infec- 
tion.    Blood  cultures  usually  demonstrate  streptococci. 

Pneumonia  arising  from  this  cause  develops  about  twenty- 
four  hours  after  birth,  in  a  child  apparently  healthy,  the  tempera- 
ture at  this  time  beginning  to  rise  and  the  respiration  growing 
more  rapid.  Cough,  although  a  variable  symptom,  is  occasion- 
ally incessant.  The  child  is  restless,  refuses  the  nipple,  is 
cyanotic,  at  times  gasps  for  breath,  and  there  may  be  dullness 
over  one  or  both  lungs.  The  diagnosis  can  not  always  be  made 
by  the  physical  signs  ;  only  a  small  patch  may  be  inv^olved. 
There  is  usually  a  history  of  dystocia.  When  a  new-born  infant 
has  a  high  temperature,  septic  pneumonia  and  general  infection 
should  be  suspected  as  the  most  probable  causes  of  the  fever. 

The  prognosis  is  grave. 


DISEASES   OF  THE  XEIV-BORN  INFANT.  943 

The  treatment  should  consist  of  stimulation — gr.  \{  to  ^ 
carbonate  of  ammonium  in  oss-oj  mucilage  of  acacia  every  four 
hours  if  it  does  not  irritate  the  stomach.  Tincture  of  digitalis, 
in  drop  doses,  should  be  given  every  two  or  four  hours.  A 
mustard-bath  once,  twice,  or  thrice  daily^  is  an  important  item  in 
the  treatment  if  there  is  cyanosis  and  very  rapid  respiration.  A 
cotton  jacket  should  be  applied.  The  mother's  milk  should  be 
drawn  from  the  breast  and  fed  to  the  infant  from  a  medicine  dropper 
in  small  quantities  every  two  hours;  a  few  drops  of  brandy  may 
be  added  to  it. 

Pulmonary  apoplexy  is  a  rare  accident  in  young  infants,  the 
result  of  severe  straining  in  crying  or  coughing.  There  is 
hemoptysis,  the  quantity  of  blood  lost  usually  not  being  very 
great,  though  it  stains  the  front  of  the  dress  and  alarms  the 
child's  caretaker  exceedingly.      The  prognosis  is  favorable. 

Syphilis  of  New=born  Infant. — Symptoms. — The  child  is 
often  ill-developed  and  ill-nourished,  but  the  characteristic  signs 
of  the  disease  do  not  usually  appear  before  four  or  six  weeks. 
In  the  order  of  their  diagnostic  value  these  signs  are  : 

Coryza  syphilitica.  The  discharge  from  the  nose  is  irri- 
tating to  the  upper  lip,  and  frequently  produces  crusts  and  even 
ulceration. 

Maculopapular  syphilide  ;  roseola,  especially  marked  on  the 
heels  ;  cutaneous  papules  and  mucous  tubercles  ;  rhagades  oris 
et  ani ;  pemphigus  ;  cutaneous  ulcers  ;  paronychiae  ;  pseudo- 
paralyses  of  extremities,  due  to  infirm  connection  between  diaph- 
ysis  and  epiphysis,  or  to  painful  periostitis  which  inhibits  motion  ; 
hemorrhagic  diathesis  ;  bone  diseases ;  fever ;  disease  of  the 
testicles,  which  are  enlarged  from  the  overgrowth  of  connective 
tissue. 

Treatment. — The  best  results  are  obtained  from  the  internal 
use  of  calomel  with  chalk  or  soda,  yV  o^  ^  grain  given  twice  a 
day,  gradually  increasing  the  dose.  Should  vomiting  or  diarrhea 
occur,  mercurial  inunctions  must  be  employed,  rubbing  a  piece 
of  mercurial  ointment  as  large  as  the  end  of  the  little  finger  on 
the  child's  abdominal  binder  every  other  day. 

This  treatment  should  be  kept  up  intermittently  for  montiis, 
being  replaced  from  time  to  time  by  tonics,  as  drop  doses  of 
syrupus  ferri  iodidi.      Tlie  child's  food  requires  careful  attention. 

Prognosis. — If  the  child  is  well  nourished  by  its  mother  or  by 
a  wet-nurse,  the  prognosis  is  very  good,  so  long  as  some  impor- 

1  The  bath  is  made  as  follows :  Three  lar<,'e  pitcherfuls  of  water  at  100°  I'".,  and 
a  tablespoonful  of  mustard  ;  allow  the  child  to  remain  in  the  bath  for  live  minutes, 
or  until  the  temperature  of  the  latter  falls  to  95°,  when  the  infant  should  be  removed 
and  wrapped,  undressed,  in  a  warmed  blanket,  in  which  it  remains  for  a  half  hour. 


944  THE  NEW-BORN  INFANT. 

tant  internal  organ  is  not  seriously  affected.  In  artificially  fed 
children  the  prognosis  is  unfavorable.  The  wet-nurse  is  liable 
to  be  infected,  and  she  should  not  be  ignorant  of  her  danger. 

Mastitis. — Four  days  after  birth  the  breasts  in  both  sexes 
contain  colostrum,  which  has  disappeared  by  the  twentieth  day. 
During  this  period  there  may  occur  in  the  breast  of  the  child 
pathological  processes  like  those  in  the  breast  of  the  puerpera. 
The  breasts  may  enlarge  and  become  painful ;  the  skin  over 
them  may  be  an  angry  red  ;  the  secretion  may  be  much  increased, 
so  that  the  milk  runs  out  in  a  stream,  and  even  a  mammary  ab- 
scess may  develop. 

Treatment. — The  nurse  must  avoid  squeezing  the  glands. 
Cooling  lotions  should  be  applied,  and  the  skin  should  be  oiled, 
to  relieve  tension.  If  suppuration  occurs,  the  abscess  should  be 
incised  without  delay,  as  there  is  always  a  tendency  for  the 
pus  to  burrow  inward  toward  the  pleura. 

Specific  or  Essential  Fevers. — Exanthemata. — The  infant 
may  exhibit  the  exanthem  at  birth  or  may  contract  the  disease 
subsequently.  The  treatment  is  the  same  as  under  other  cir- 
cumstances. 

Septic  infection  occurs  by  inspiration  of  infected  discharges 
from  the  vagina  during  birth  or  through  the  umbihcus.  The  most 
important  treatment  is  the  preventive  (see  Diseases  of  Umbilicus). 
The  infection  of  the  umbilicus  usually  occurs  in  the  first  two  weeks 
of  life,  but  the  symptoms  may  appear  as  late  as  the  fourth  week. 

The  Treatment  of  Certain  Congenital  Deformities. — ^Hare= 
lip. — This  deformity  may  prevent  suckling  ;  if  so,  an  immediate 
plastic  operation  is  indicated,  which  may  be  undertaken  in  the 
first  few  hours  of  life. 

The  operation  for  cleft=palate  is  too  serious  to  be  undertaken 
during  early  infancy.  A  rubber  flap  over  the  nipple  of  the  bottle 
may  enable  the  child  to  suck.     It  can  not  nurse  from  the  breast. 

Supernumerary  digits  should  be  ligated  and  cut  off.  If  they 
are  mere  fleshy  appendages,  a  thread  may  be  tied  around  their 
base,  and  they  may  be  left  to  fall  off. 

In  a  tongue^'tie  the  frenum  should  be  snipped  superficially 
with  blunt-pointed  scissors,  and  then  torn  with  the  fingers  to  the 
floor  of  the  mouth.  The  child's  head  is  placed  between  the 
knees  of  the  operator ;  the  two  first  fingers  of  the  left  hand  are 
inserted  on  either  side  of  the  frenum,  to  hold  the  mouth  open 
and  to  protect  the  tongue  from  injury. 

Umbilical  Hernia. — There  are  two  varieties  of  this  deformity. 
In  one,  a  knuckle  of  intestine  covered  by  skin  projects  from  the 
navel.  This  degree  of  deformity  is  common,  occurring  in  two 
per  cent,  of  infants.  It  is  treated  by  a  convex  button,  cork,  or 
hard-rubber   compress   on    a   strip   of    adhesive   plaster,    which 


DISEASES   OF   THE   NEW-BORN  INFANT.  945 

encircles  two-thirds  of  the  child's  body.  This  improvised  truss 
is  renewed  from  time  to  time,  and  should  be  worn  six  months. 
In  the  second  variety  there  is  an  exomphalic  condition,  due  to 
defective  development,  the  intestines  protruding  from  the  umbili- 
cus covered  only  by  amnion.  An  immediate  plastic  operation  is 
indicated  even  if  the  mass  of  protruding  intestines  is  as  large  as 
an  apple.      The  results  of  this  operation  have  been  excellent. 

Spina  bifida  is  to  be  distinguished  from  the  less  serious  con- 
ditions— fibroma,  myxoma,  or  lipoma  of  buttocks — and  from 
parasitic  teratomata.  In  spina  bifida  a  hardened  patch  is  found  at 
the  prominence  of  the  tumor,  due  to  the  attachment  at  that  point 
of  the  Cauda  equina. 

Treatment. — Lay  the  tumor  open,  dissect  out  the  sac,  make 
traction  upon  the  latter,  when  the  cauda  equina  will  retreat  into 
the  canal  ;  ligate  with  catgut  the  pedicle  formed,  and  accurately 
close  up  the  wound  with  buried  catgut  sutures,  with  strict  asep- 
sis. The  prognosis  is  not  good.  If  the  child  survives  the  opera- 
tion, it  is  not  unlikely  to  die  of  hydrocephalus. 

Imperforate  Rectum. — The  anus  and  rectum  should  be  exam- 
ined immediately  after  birth  in  all  cases.  To  avoid  the  danger 
of  fecal  accumulation,  inguinal  or  lumbar  colotomy  may  be 
necessaiy.  In  simple  cases  with  merely  a  transverse  septum 
between  the  anus  and  the  rectum,  a  cruciform  incision  over  the 
imperforate  anus  is  sufficient  to  open  the  rectum.  The  mucous 
membrane  of  the  bowel  is  then  stitched  to  the  skin  of  the  anus. 
An  attempt  should  alwax^s  first  be  made  to  reach  the  rectum 
from  the  perineum.  I  have  succeeded  in  one  case  in  which  it  was 
necessary  to  make  a  blunt  dissection  two  inches  up  into  the  infant's 
pelvis.      Should  this  attempt  fail,  colotomy  is  necessary. 

Technic  of  Inguinal  Colotomy  for  Atresia  Ani. — Make  an  in- 
cision above  and  parallel  with  Poupart's  ligament  on  the  left 
side  ;  deliver  the  distended  sigmoid  flexure  ;  put  two  stitches 
through  it,  one  on  each  side  of  the  bowel,  the  threads  running 
parallel  with  one  another  and  with  the  long  axis  of  the  bowel, 
the  two  ends  of  each  stitch  entering  and  emerging  from  the 
bowel-wall  about  a  quarter  of  an  inch  apart ;  incise  the  bowel 
between  the  two  stitches,  pulling  it  well  down  below  the  abdom- 
inal wound,  to  guard  the  peritoneal  cavity  from  contamination, 
as  meconium  and  gas  make  their  escape.  Making  the  wound  in 
the  bowel  gape  by  pulling  upon  the  ligatures  through  its  wall, 
a  few  interrupted  sutures  arc  passed  through  the  bowel  at  the 
site  of  the  opening  and  the  abdominal  wall,  fastening  the  two 
together.  Finally,  the  edges  of  the  abdominal  and  bowel  wound 
are  whipped  together  with  a  continuous  catgut  stitch,  to  prevent 
hemorrhage  from  the  former.  An  anesthetic  is  not  absolutely 
necessary.  I  have  seen  the  infant  nui'sing  contentedly  fr(~)m  its 
60 


946  THE   NEW-BORN  INFANT. 

mother's  breast  five  minutes  after  such  an  operation.  Later^, 
the  rectum  may  be  probed  from  above  to  determine  the  depth 
of  the  incision  necessary  to  reach  it  from  the  anus. 

Nasal  Catarrh  (Snuffles). — Causes. — When  the  disease  is 
not  syphihtic,  it  is  due,  usually,  to  faulty  clothing  or  to  drafts 
of  air.  The  crib  should  be  protected,  and  the  child  should  wear 
a  thin  lawn  cap  until  its  head  is  covered  by  a  growth  of  hair. 

Diseases  of  the  Mouth. — Aphthae  are  rounded,  pearl-colored 
vesicles  seen  in  the  mouth  and  on  the  lips.  Washing  the  mouth 
daily  with  a  clean  linen  towel  will  prevent  them.  Boric  acid,  gr. 
v— X  to  the  ounce,  as  a  wash,  is  curative. 

In  true  thrush  there  is  a  coalescence  of  white  spots,  with  an 
areola  of  reddened  mucous  membrane.  The  disease  is  often  seen 
in  hospital  practice,  or  in  infants  whose  hygienic  surroundings 
are  bad.  It  is  due  to  the  presence  of  a  parasite,  the  saccharo- 
myces  albicans. 

Treatment. — Boric  acid,  gr.  xvj— xx  to  §j  of  honey.  One-half 
of  a  dram  of  this  mixture  is  put  in  the  mouth  three  or  four  times. 
a  day.  The  associated  symptoms  of  malnutrition,  diarrhea,  and 
vomiting  indicate  attention  to  hygienic  surroundings,  to  the 
general  health  of  the  child,  and  to  its  diet. 

In  gonorrheal  stomatitis  there  is  violent  inflammation  of  the 
oral  mucous  membrane,  due  to  the  presence  of  gonococci. 
Cleanliness  and  mild  disinfection  of  the  mouth  with  boric  acid 
solution  will  effect  a  cure.  The  disease  is  rare.  I  have  seen 
but  one  case  in  all  my  hospital  services. 

Sublingual  cysts  are  probably  the  result  of  the  occlusion  of 
the  duct  of  a  submaxillary  gland.  The  cys!:  appears  in  the  first 
few  days  after  birth,  and  ma}^  reach  such  a  size  as  to  displace  the 
tongue  and  to  interfere  with  sucking.  The  treatment  consists  of 
puncture  of  the  cyst,  which  does  not  return. 

Colic,  Diarrhea,  Constipation. — Colic  always  indicates  a 
careful  attention  to  diet.  Medicinally,  gr.  j  of  pepsin  may  be  given 
in  3J  of  hot  water,  with  a  i&v^  drops  of  brandy  or  gin.  Milk  of 
asafetida,  gtt.  xx-xl,  or  soda-mint,  ^j,  m~ay  be  used,  and  a  spice- 
plaster  may  be  applied  to  the  abdomen. 

Diarrhea  indicates  almost  always  some  error  in  the  diet. 
Frequent  serous  movements,  draining  the  child's  strength  and 
demanding  a  remedy,  may  be  checked  with  the  following  : 

B; .      Acid,  sulphuric,  aromat., 

Tinct.  opii  camph., aa     gtt.  iv. 

One  dose,  not  to  he  repeated. 

Constipation. — In  simple  cases  a  dose  of  castor  oil  (^j),  the 
soap-stick,  a  glycerin  suppository  or  injection  (gtt.  xv-xx  in  {-^y 
of  water)  suffice,  or  the  following  may  be  used  : 


DISEASES    OF    THE   NEW-BORN  INFANT.  947 

R .      Calcined  magnesia, 

Sugar  of  milk, of  each    7  '2  grains. 

For  chronic  constipation  the  daily  injection  of  warm  soap- 
suds (f§ij)  by  a  soft-bulb  rubber  ear-syringe  is  least  harmful. 

Medicinally,  the  treatment  may  consist  of  a  piece  of  flake 
manna  in  each  bottle  of  artificially  fed  children  ;  the  administra- 
tion of  ten  drops  of  the  syrup  of  figs,  with  two  to  four  drops  of  the 
fluid  extract  of  cascara ;  a  pinch  of  salt  in  the  bottles  ;  the  addi- 
tion of  Mellin's  food,  and  daily  abdominal  massage  ;  the  addition 
to  each  bottle  of  milk  of  two  to  four  grains  phosphate  of  soda  ;  an 
increase  in  the  proportion  of  cream  ;  Tarrant's  Seltzer  Aperient 
(ten  grs.)  in  the  milk  ;  a  little  milk  of  magnesia,  added  to  one  or 
more  bottles  or  given  in  water  to  a  nursing  baby. 

Intussusception. — In  a  case  in  the  University  Maternity,  the 
child  died  forty-eight  hours  after  birth.  The  symptoms  began  in 
the  first  twenty-four  hours  ;  the  child  passed  blood  and  mucus 
by  the  bowel,  developed  high  fever,  and  vomited  incessantly. 
Postmortem  examination  showed  the  intussusception  in  the 
ileum  ;  the  bowel  above  was  much  distended  ;  below,  inflamed 
and  very  dark  in  color  for  a  couple  of  inches. 

Skin  Diseases. — Gum,  a  sort  of  acne,  is  due  to  the  irritation 
of  the  skin  by  the  atmosphere  and  the  clothing.  It  is  exceed- 
ingly common. 

Treatment. — Cleanliness,  proper  clothing,  and  some  simple 
ointment,  perhaps  as  a  salve  to  the  mother's  anxiety  as  much  as 
to  the  infant's  skin. 

FuriLiiclcs  are  likely  to  be  small  and  numerous.  The  condi- 
tion is  an  exaggeration  of  gum,  with  enlargement  and  suppura- 
tion of  the  pimples. 

The  diet  and  hygienic  surroundings  should  be  investigated. 
The  small  boils  may  be  washed  twice  daily  with  a  solution  of 
boric  acid,  gr.  xv,  and  resorcin,  gr.  iij-fsj,  and  boric  acid 
ointment,  .3J-.5J,  ung.  aq.  rosse,  may  be  applied.  The  boils  may 
be  opened  with  a  needle  when  they  come  to  a  head. 

Simple  acute  pemphigus  is  very  rare.  From  the  second  day 
to  the  fourth,  fifth,  or  sixth  week,  vesicles  the  size  of  a  pea  to  a 
quarter-  or  half-dollar  appear  indifferently  over  the  whole  body, 
except  the  soles  of  the  feet  and  the  palms  of  the  hands.  The 
disease  lasts  from  twelve  to  fourteen  days,  without  manifestation 
of  constitutional  disturbance. 

It  is  contagious,  and  may  be  carried  by  the  nurse  or  be  com- 
municated to  a  mother  or  nurse.  It  disappears  without  treat- 
ment. A  specific  micro-organi.sm,  it  is  claimed,  ha.s  been  discovered, 
but  the  slaphyk)C()ccus  pyogenes  aureus  is  generally  regarded  as 
the  infecting  ajienl. 


948  THE  NEW-BORN  INFANT. 

Syphilitic  pemphigus  usually  begins  in  utero,  and  the  child  is 
born  with  the  vesicles  upon  it,  the  soles  of  the  feet  and  the  palms 
of  the  hands  being  most  often  affected.  The  disease  is  associated 
with  marked  evidence  of  malnutrition  and  constitutional  disturb- 
ance, and  yields  only  to  specific  treatment. 

Ophthalmia  Neonatorum. — Symptoms. — True  ophthalmia  is 
the  result  of  the  infection  of  the  conjunctivae  by  gonococci. 
Usually  after  twenty -four  to  forty-eight  hours  the  eyelids  are 
edematous  and  puffed  out,  and  between  them  there  appears  a 
seropurulent  discharge,  which  soon  becomes  greenish-yellow 
pus,  and  in  which  gonococci  are  found  under  the  microscope. 
When  the  lids  are  separated,  the  conjunctivae  are  seen  to  be  red 
and  velvet-like  in  appearance,  and  later  the  cornea  may  lose  its 
epithelium,  become  glazed,  ulcerate,  and  be  perforated. 

Treatment,  Prophylactic. — As  soon  as  the  head  is  born,  the 
orbital  region  is  wiped  clean  with  soft  linen  squares,  soaked  in  a 
boracic  acid  solution.  When  the  delivery  is  completed,  the  eyes 
are  again  cleansed  by  injecting  into  the  conjunctival  sacs  boracic 
acid  solution  (gr.  x  to  aq.  destil.  fSj)  by  an  eye-dropper.  In 
hospital  practice  uniformly,  in  private  practice  if  there  is  reason 
to  suspect  a  gonorrheal  infection  of  the  mother's  vagina,  several 
drops  of  a  25  per  cent,  solution  of  argyrol  are  instilled  in  the  eyes.^ 

Curative. — The  eyes  are  cleansed  every  hour,  day  and  night, 
with  a  concentrated  solution  of  boric  acid.  Cold  compresses 
are  kept  upon  the  lids.  Morning  and  evening  argyrol  solution,  25 
per  cent.,  is  instilled.  If  only  one  eye  is  affected,  the  other  should 
be  carefully  bandaged  with  a  pledget  of  hnt  to  protect  it.  A  drop 
of  a  weak  solution  of  atropia  is  occasionally  required.  If  possible, 
the  case  should  be  placed  under  the  care  of  an  oculist.  The 
author  invariably  refuses  to  accept  the  responsibility  of  treating 
such  a  case.  The  mouth,  the  nose,  and  the  ears  of  a  new-born 
infant  may  be  the  seat  of  gonorrheal  inflammation. 

There  is  frequently  a  subacute  conjunctivitis  after  birth, 
often  affecting  one  eye  alone,  and  yielding  to  the  mildest  treat- 
ment, or  disappearing  spontaneously.  The  inexperienced  phy- 
sician not  infrequently  mistakes  this  innocuous  inflammation  for 
ophthalmia,  and  by  the  injudicious  energy  of  his  treatment  con- 
verts a  mild  into  a  very  severe  conjunctivitis.  I  have  seen  per- 
manent opacity  of  the  corneae  from  the  unnecessary  use  of 
nitrate  of  silver  in  such  a  case.  The  severest  possible  inflamma- 
tion, ending  in  total  blindness,  has  resulted  from  the  injection  of 
sublimate  solution  in  the  vagina  during  labor,  the  corrosive  sub- 
limate gaining  access  to  the  child's  eyes  and  causing  inflamma- 
tion and  perforation  of  the  corneae. 

'  See  Christian,  "  Medical  Record,"  vol.  Ixii,  1902. 


DISEASES   OF  THE  iVElV-BOAW  INFANT.  949 

Hemophilia  is  an  inherited  pathological  disposition  to  bleed 
from  apparently  normal  or  slightly  injured  surfaces.  The  manner 
of  transmission  is  peculiar;  it  is  always  through  the  mother  to 
male  children,  who  do  not  transmit  it.  The  female  children  are 
said  to  show"  no  e^^dence  of  the  disease,  but  transmit  it.  The 
cause  is  not  know^n,  and  it  manifests  itself  throughout  life.  Treat- 
ment is  of  no  avail.  If  should  be  remembered  that  a  hemorrhagic 
diathesis  is  sometimes  due  to  syphilis,  and  in  such  cases  specific 
treatment  is  of  value.  I  have  seen  a  hemophilic  infant  bleed  to 
death  from  its  conjunctivae,  incessantly  weeping  tears  of  blood, 
and  another  lose  its  life  from  hemorrhage  following  a  superficial 
abrasion  under  the  tongue.  Dr.  AI.  D.  Hoyt  gives  me  the  notes 
of  a  female  infant  which  bled  to  death  from  its  wrists,  ankles 
(hemidrosis),  cord,  nose,  and  lungs.  The  hemorrhage  continued 
four  days. 

Icterus. — There  are  two  classes  of  cases  : 

In  the  first  the  jaundice  is  slight  in  degree.  The  face  and 
breast  only  are  affected.  This  grade  of  jaundice  is  very  com- 
mon, the  majority  of  children  manifesting  it. 

The  cause  is  said  to  be  hepatogenic.  The  very  small  com- 
mon biliary  duct  fails  to  empty  into  the  bowel  the  excess  of  bile 
produced  by  the  liver.  The  discoloration  disappears  a  few  days 
after  birth,  and  the  condition  usually  requires  no  treatment. 
Fractional  doses  of  calomel  may  be  given  if  the  child's  digestion 
is  impaired,  or  if  the  jaundice  is  deeper  than  common. 

In  the  second  variety  the  whole  body  is  jaundiced.  The 
urine  and  feces  are  discolored,  and  may  contain  blood.  This 
variety  is  decidedly  rare,  and  is  a  manifestation  of  grave  systemic 
derangement,  usually  general  septic  infection. 

Causes. — This  kind  of  jaundice  is  sajd  also  to  be,  as  a  rule, 
hepatogenic.  It  is  seen  in  Buhl's  and  VVinckel's  disease,  in 
atresia  of  the  bile-duct,  and  in  polycystic  disease  of  the  liver. 
In  streptococcic  infection  of  the  blood-current  producing  disinte- 
gration of  the  blood,  the  jaundice,  I  believe,  is  in  part  hemato- 
genic, resulting  from  a  disintegration  of  the  blood-corpuscles. 

The  prognosis  of  the  inaliguaut  variety  is  extrcjncly  grave. 
The  result  is  almost  invariably  fatal. 

Cyanosis  was  once  thought  to  be  s)'nonymous  with  congeni- 
tal heart  disease.  The  laity  still  regard  a  "blue  baby"  as  one 
with  a  defective  heart. 

The  causes  of  cyanosis,  in  the  order  of  their  frequency,  are  : 
pneumonia  (often  syphilitic),  premature  birth,  asphy.xia,  atelec- 
tasis, degeneration  of  the  blood,  malformation  of  the  heart  and 
blood-vessels,  interference  with  the  function  of  the  nerves  of 
respiration,  malformation  of  the  respiratory  tract,  congenital 
pleurisy,  and  partial  occlusion  of  the  trachea. 


950  THE   NEIV-BORX  IXFAXT. 

Congenital  heart  affections  may  result  from  intra-uterine 
endocarditis,  as  stenosis  of  the  right  and  left  auriculoventricular 
orifices,  stenosis  of  the  aortic  and  pidmonary  orifices,  and  insuffi- 
ciency of  the  valves.  Or  they  may  be  the  result  of  defective 
development,  as  patency  of  the  foramen  ovale,  atresia  of  the 
pulmonary  arter}^,  stenosis  of  the  conus  arteriosus,  and  defects 
in  the  ventricular  septum. 

A  child  with  congenital  heart  disease  must  be  managed  with 
extraordinary'  care.  Exposure  to  cold  is  particularly  danger- 
ous, as  there  is  a  tendency  to  pulmonan,'  congestion  and  pneu- 
monia. Artificial  heat  may  be  necessary  ;  malnutrition  must  be 
combated ;  heart  tonics  may  be  required.  The  prognosis  is 
relatively  favorable.  Compensation  may  often  be  secured  in 
apparently  the  most  unfavorable  cases. 

Diseases  of  Umbilicus. — Septic  Infection. — The  ulcer  on  an 
infected  umbilicus  is  covered  with  a  grayish,  diphtheritic  mem- 
brane, has  a  reddened  areola,  and  the  local  inflammation  leads 
to  general  infection.  An  acute,  high  fever  in  a  new-born  infant 
suggests  septic  infection  or  pneumonia.  The  latter  may  be  sep- 
tic. The  so-called  Buhl's  and  Winckel's  diseases,  with  fatty 
degeneration  of  the  organs,  icterus,  cyanosis,  and  hemoglob- 
inuria, are  merely  the  result  of  streptococcic  infection  of  the 
blood-current. 

Treatment,  Propliylactic. — The  ulcer  should  be  exposed  at  the 
daily  bath,  cleansed  with  soap  and  water,  and  dressed  with  sali- 
cylic acid,  I  part ;  starch,  5  parts.  An  aseptic  ligature  should 
always  be  used  to  ligate  the  cord  at  birth,  and  the  daily  dressing 
of  the  cord  with  fresh  salicylated  cotton  should  be  carefully 
carried  out  with  clean  hands  until  the  cord  drops  off. 

Curative  Treatment. — The  ulcer  should  be  touched  with  a 
solution  of  bichlorid  of  mercuiy-,  i  :  500,  or  with  nitrate  of  silver 
solution,  .5J-f3J.  It  should  be  thoroughly  irrigated  and  dusted 
with  salicylic  acid  and  starch,  and  covered  with  salic}'lated 
cotton. 

Umbilical  fungus  is  usually  an  overgrowth  of  granulation 
tissue.  It  projects  in  a  mass  like  a  strawberry  from  the  navel. 
It  should  be  cauterized  with  a  solid  stick  of  nitrate  of  silver, 
whereupon  it  promptly  melts  away.  In  about  one-fifth  of  the 
cases  cauterization  fails,  the  tumor  is  more  solid  in  feel,  and  is 
found,  on  microscopic  investigation,  to  be  the  remains  of  the  om- 
phalic duct.  This  kind  of  umbilical  fungus  is  called  an  entero- 
teratoma.  It  should  be  ligated  and  cut  off.  The  stump  of  the 
cord  may  persist,  unchanged,  almost  indefinitely,  covered  with  an 
angry,  red  layer  of  granulation  cells,  or  a  spur  of  well-organized 
connective  tissue  may  project  from  the  umbilicus.     In  such  cases 


DISEASES    OF   THE   NEU'-BOR.Y  E\'FAKT.  95  I 

there  is  a  small  supply  of  blood  to  the  cord  in  spite  of  the  liga- 
ture. The  projecting  mass  must  be  cut  off.  I  have  been  obliged 
to  amputate  the  persistent  stump  of  a  cord  on  the  sixteenth  day. 

Omphalitis  is  a  peculiar  inflammation  of  the  umbilicus  and 
surrounding  structures,  in  which  the  abdomen  becomes  conical 
in  shape  ;  the  skin  and  subcutaneous  connective  tissue  are  hard, 
red,  and  infiltrated.  It  is  always  septic  in  origin.  It  requires  dis- 
infection of  the  umbilicus,  poultices,  and  early  incisions,  with 
stimulants  and  supporting  treatment.  A  later  stage  of  the  in- 
flammation is  gangrene.  The  prognosis  is  very  grave.  It  is 
difficult  to  avert  general  systemic  infection. 

Inflammation  of  the  umbilical  vessels  is  always  due  to  septic 
infection,  and  invariably  leads  to  systemic  infection,  which  is 
commonly  fatal. 

Hemorrhage  from  the  Umbilicus  (Omphalorrhagia). — The  bleed- 
ing may  come  from  the  cord  or  from  the  umbilical  ulcer.  It 
may  be  primary,  from  careless  ligation  of  the  cord  ;  or  second- 
ary, after  the  cord  drops  off.  The  vessels  of  the  cord  close  from 
the  placental  end  inward,  and  the  hypogastric  arteries  may  be 
patulous  after  the  cord  drops  off,  when  increased  blood-pressure 
or  handling  the  ulcer  may  bring  on  hemorrhage.  The  mortality 
of  this  accident  is  computed  at  seventy-six  to  eighty-three  per 
cent. 

Treatment. — In  primary  hemorrhage  the  cord  must  be 
promptly  re-ligated.  In  bleeding  from  the  umbilical  stump,  if 
the  bleeding  vessels  are  seen,  they  should  be  ligated.  Usually, 
it  is  impossible  to  isolate  the  bleeding  vessels.  In  such  cases 
the  hemorrhage  may  be  controlled  by  Monsel's  solution  and 
pressure  by  liquid  plaster-of-Paris  poured  into  the  navel,  where 
it  "sets,"  by  powdered  suprarenal  extract,  or  by  successive 
layers  of  powdered  bismuth,  with  gauze  and  collodion.  Ergotin 
hypodermatically  (gr.  ss),  gallic  acid  (gr.  j)  by  the  mouth,  and 
gelatin  (5  c.c.  of  a  10  per  cent,  solution  in  sterile  normal  salt 
solution)  hypodermatically  should  be  employed  in  addition  to  the 
local  treatment.  As  a  last  resort,  the  abdominal  wall  arountl 
the  navel  should  be  transfixed  with  harelip  pins  or  ordinar\'  large- 
sized  needles,  and  a  figure-of-eight  ligature  should  be  applied 
under  them.  If  there  is  sufficient  stump  of  the  cord  left,  it 
should  be  drawn  out  and  transfixed  with  two  pins  or  needles  and 
ligated  below  them.  I  was  able  to  check  a  hemorrhage  in  this 
way  several  da)'s  after  the  cord  had  dropped  off.  If  this  is  im- 
possible, one  pin  and  a  ligature  may  suffice;  it  should  transfix 
the  abdominal  wall  just  below  the  umbilicus,  so  as  to  occlude 
the  hypogastric  arteries.  Ik-fore  inserting  the  pin  the  abdominal 
walls  should  be  compressed  and    rolled   between  the  thumb  and 


952 


THE  NEW-BORN  INFANT. 


forefinger  to  get  rid  of  coils  of  intestines.  Should  the  hemor- 
rhage continue,  it  can  be  controlled  by  a  pin  and  a  ligature  above 
the  umbilicus  to  occlude  the  umbilical  vein. 

Tetanus  of  the  new=born  is  the  result  of  the  entrance  of 
tetanus  bacilli  through  the  umbilicus.  The  disease  in  temperate 
climates  occurs  almost  exclusively  in  hospitals.  It  is  usually 
fatal,  the  death-rate  being  over  ninety  per  cent.     The  treatment 


Fig.  776. — Atresia  of  the  ureter:  A,  Kidney;  B,  ureter;   C,  bladder   (author's  case 
in  University  Maternity). 


should  always  include  an  immediate  and  a  thorough  disinfection 
of  the  navel. 

Melena,  or  gastro=intestinal  hemorrhage,  is  an  extravasation 
of  blood  into  the  stomach  and  intestines,  occurring  most  often  in 
the  first  few  hours  of  life.  Duodenal  ulcer,  some  congenital  defect 
increasing  intra-abdominal  blood-pressure,  intussusception,  or 
hemophilia  may  be  the  cause.  The  child  may  vomit  bright,  un- 
altered blood,  or  the  vomit  may  be  "  coffee-grounds  "  in  charac- 
ter. The  blood  from  the  bowel  is  black  in  color,  and  is  mixed 
with  meconium,  hence  the  name  melena.  It  is  to  be  carefully 
distinguished  from  the  vomitin"-  of  blood  derived  from  a  fissured 


DISEASES    OF   THE   AEU'-BORN  EXFAXT.  953 

nipple  in  the  mother  and  ingested  with  the  milk.  In  melena  the 
infant  shows  unmistakable  symptoms  of  internal  hemorrhage. 

Treatment. — Gallic  acid,  gr.  ij,  may  be  given  every  hour, 
Ergotin  hypodermatically,  an  ice-bag  to  the  abdomen,  and  hot 
bottles  to  the  flanks  and  thighs.  Stimulation  may  be  required. 
The  mortalit\%  in  spite  of  intelligent  and  energetic  treatment,  is 
fifty  per  cent. 

Bloody  discharge  from  the  genitalia  of  female  children  is 
not  very  rare.  It  shows  an  activity  of  the  sexual  organs  anal- 
ogous to  the  breast  changes  in  the  new-born.  The  condition  is 
not  dangerous,  and  requires  no  treatment.  The  blood  comes 
from  the  uterus,  like  the  menstrual  discharges — in  fact,  the  dis- 
charge is  a  true  menstruation,  as  has  been  demonstrated  in 
postmortem  examinations  of  infants  who  died  from  intercurrent 
affections.  It  appears  three  or  four  days  after  birth,  and  lasts 
only  a  few  days. 

Sudden  death  of  apparently  healthy  children  is  an  accident 
not  infrequently  demanding  an  explanation  by  the  attending 
physician. 

Among  the  causes  may  be  found  overlying  by  the  mother, 
accidentally  or  intentionally.  In  one  of  the  reports  of  the  Regis- 
trar-general of  England,  there  was  a  record  of  1500  cases,  the 
majority  occurring  on  Saturday  night ! 

Diseases. — Most  commonly  pneumonias,  apoplexies,  more 
rarely  perforation  or  intussusception  of  the  bowels,  rupture  of  a 
large  viscus,  or  any  of  the  diseases  previously  described,  which 
had  not  been  detected  during  life. 

Occlusion  of  the  trachea  by  an  enlarged  thymus  or  by  curds  of 
milk. 

Congenital  deformities  of  important  internal  organs,  as  atresia 
of  the  ureter. 

Medication  of  the  New=born. — In  administering  medicine  to 
a  newly  born  infant,  the  physician  should  remember  its  peculiar 
intolerance  of  opium  and  its  tolerance  of  some  other  remedies. 

The  following  are  some  of  the  drugs  and  their  doses  re- 
quired in  the  first  four  weeks  of  life  :  Opium,  only  as  paregoric, 
from  two  to  five  drops  in  one  dose,  not  repeated  ;  mercury,  always 
as  calomel,  -jV  to  i  gr.  ;  ca.stor  oil,  i  5  gtt.  to  .^j  ;  nitrate  of  silver, 
-^\.o  ^  gr.  ;  pepsin,  gr.  j-ij  ;  gallic  acid,  gr.  ss-ij,  etc. 


INDEX 


Abdomen,  appearance  of,  in  pregnancy, 

changes  in  size  and   shape,   in   preg- 
nancy, 193 
flatulent    distention    of,    in    puerperal 

state,  686 
gauze  pad  for,  781 
preparation  of,  for  abdominal  section, 

781 
Abdominal  binder,  341 

in  postpartum  hemorrhage,  5S7 

Storm,  921 
hysteromyomectomy,  911 
muscles,  contraction  of,  in  labor,  333 

diastasis  of,  in  labor,  620 
in  puerperal  state,  686 
pad  after  labor,  341 
palpation  at  end  of  puerperium,  384 

diagnosis  of  position  of  fetus  by,  389 

in  labor,  388 

in  pregnancy,  200 
pregnancy,  285 

clinical  histor\',  292 

death  of  fetus  in,  299 

secondar}',  285 

symptoms,  304 
section,  care  of  bowels  after,  901 

catheterization  before,  782 

closure  of  wound,  900 

drainage  after,  901 

dress  of  patient  for,  782 

exploratory,  for  puerperal  sepsis,  751 

for  abdominal  tumors,  910 

for  dilTuse    supjjuralive    peritonitis, 

744 
for  interstitial  pregnancy,  307 
for  intrajjeritoneal  aliscess,  744 
for  ]jelvic  tumors,  910 
for  retrodisplacemenl  of  uterus,  917 
for  tubal  pregnancy,  306 
for  ureteral  fistula,  891 
in  [juerijcral  sepsis,  741 
incision,  899 
])rei)aration  for,  780,  864,  899 

afternoon  before  operation,  780 

in  ])rivale  houses,  899 

morning  of  <. iteration,  781 

of  abdomen  in,  781 

of  nurse  for,  781 
su])porter,  Patterson's,  217 


Abdominal    tumors,    abdominal    section 
for,  910 

pregnancy  and,  204 
differentiation,  204 

putrefaction  of,  768 
walls,  changes  in,  in  pregnane},  185 
Abortion,  267 

after-treatment,  283 

appearance  of  ovum  after,  275 

causes,  268 

cholemic  convulsions  in,  270 

chorea  in,  269 

clinical  history,  271 

phenomena,  272 
diagnosis,  276 
duration,  272 
eclampsia  in,  269 
epilepsy  in,  270 
frerjuency,  271 

from  abnormal  position  of  uterus,  270 
from  accidents  to  mother,  266 
from  alterations  in  maternal  blood,  270 
from  anemia,  175 
from  cholera,  162 
from  chronic  endometritis,  175 
from  convulsions,  270 
from  coughing,  269 
from   diffuse   hyperplasia   of   decidual 

endometrium,  149 
from  eclampsia,  269 
from  heart  disease,  257 
from  injuries  of  mother,  266 
from  irritable  uterus,  268 
from  maternal  dialjetes,  176 
from  metritis,  175,  223 
from  o\-erdistenlion  of  uterus,  271 
from  ])()isoning  of  mollicr,   176 
from  [jrolapsc  of  uterus,  270 
from  renal  cahulus,  251 
from  rctroOexion  of  uterus,  270 
from  spasmodic  muscular  action   in 

mother,  269 
from  tvjjhoid  fever,  162 
from  vomiting,  269 
hemorrhage  in,  272 
hydramnios  in,  271 
hysterical  convulsions  in,  270 
in  multiple  fetation,  96 

I)regnancy,  271 
in  placenta  pr;e\'ia,  577 

955 


956 


INDEX. 


Abortion  in  retrodisplacement  of   preg- 
nant uterus,  218 
induction  of,  797 
indications  for,  797 
methods  of,  798 
nephritis  in,  248 
inevitable,  diagnosis  of,  277 
Tarnier's  sign,  277 
treatment  of,  281 
active,  282 
expectant,  282 
missed,  283 
pain  in,  272 
partially     or     wholly     accomplished, 

diagnosis,  278 
prognosis,  279 
threatened,  diagnosis  of,  276 

treatment  of,  280 
treatment  of,  279 
tubal,  300 
Abscess,  intraperitoneal,  abdominal  sec- 
tion for,  744 
ischiorectal,  in  puerperal  sepsis,  769 
of    Bartholin's   gland,    obstruction    of 

labor  by,  537 
of  breasts,  709 

in  pregnancy,  236 
of  placenta,  130 
postmammary,  711 
suburethral,  in  pregnancy,  229 
Absence  of  breasts,  693 
Acanthopelys,  498 
Acardia  in  multiple  fetation,  96 
Accessory    corpuscle    of    spermatozoon, 

70 
Accidental  hemorrhage,  572,  583 
Accidents  of  labor,  623 

of  pregnancy,  266 
Accouchement    force    for    induction    of 
premature  labor,  800 
in  eclampsia,  640 
Acetabulum,  fracture  of,  502 
Acetonuria  in  pregnancy,  253 

in  ruptured  extra-uterine   pregnane}^, 

305 
Achondroplasia  of  fetus,  164 
Achondroplastic  pelvis,  473 
Adhesions  of  placenta,  435 
causes,  436 
diagnosis,  436 
treatment,  436 
peri-uterine,  in  pregnancy,  235 
Adipocere,  174 

After-birth,  120.     See  also  P/accn/fl. 
After-coming  head,  delivery  of,  by  for- 
ceps, 841 
Deventer's  method,  841 
Mauriceau's  method,  839 
Prague's  method,  840 
Wigand's  method,  838 
After-pains,  356 
Agalactia,  696 


Agglutination  of  labia,  treatment  of,  865 
Albuminuria  as  indication  for  inducing 
abortion,  797 

from  death  of  fetus,  173 

in  pregnancy,  253 
Alimentary  canal  diseases  in  pregnancy, 

237 
AUantois,  136 
Alr^uie-Alexander-Adams    operation    for 

retrodisplacement  of  uterus,  914 
Amnion,  abnormalities  of,  102 
of  secretion,  102 

adhesive  inflammation  of,  108 

anatomy  of,  100 

cysts  of,  109 

development  of,  98 

dropsy  of,  103 

fully  developed,  100 
Amniotic  bands,  formation  of,  108 

fluid,  100.     See  also  Liquor  amnii. 
Amniotitis,  105 
Amphiarthroses,  20 
Amphitheater,  clinical,  774 
Amputation,  intra-uterine,  166 

of  cervix  uteri,  898 

Hegar's  method,  898 

of  clitoris,  indications  for,  866 

of  fetal  parts  to  effect  delivery,  849 

of  labia,  indications  for,  866 
Anasarca,  559 

of  fetus,  164 
Anastomosis,  ureteral,  for  ureteral  fistula^ 

889 
Anemia,  abortion  from,  175 

pernicious,  in  pregnancy,  261 

puerperal,  648 
Anesthesia  in  obstetric  operations,  783 
Anesthetics  in  labor,  329,  330 
Anesthetization  in  eclampsia,  636 
Aneurysm  in  pregnancy,  260 
Ankylosis  in  fetus,  166 

of  pelvic  joints,  504 

of  sacrococcygeal  joint,  504 
Annular  placenta,  127 
Anteflexion  of  gravid  uterus,  215 

treatment,  216 
Antepartum    fetometr}',    465.     See    also- 

Fetometry,  antepartum. 
Anteroposterior  diameter  of  pelvic  inlet, 
measurement  of,  448 
outlet,  measurement  of,  465 
of  pelvis,  22 
Ante-uterine  hematocele,  302 
Anus  vaginalis,  obstruction  of  labor  by, 

vestibularis,   obstruction  of  labor  by,, 

535  . 

Aphasia  in  puerperal  state,  692 

Apo])lexies  in  pregnancv,  254 
in  jjuerjjeral  state,  692 
pulmonary,  of  new-born,  944 

Appendicitis  in  pregnancy,  243 


INDEX. 


957 


Appetite  in  puerperal  state,  359 
Arbor  vita;  of  uterus,  47 
Areola  in  pregnancy,  194 

inflammation  of,  703 
Argyrol  in  puerperal  sepsis,  740 
Armamentarium  for  labor,  325 
Arms,  delivery  of,  after  podalic  version, 

836 
Arthritis  in  puerperal  state,  683 
Articular  rheumatism  of  fetus,  162 
Artificial  dilatation  of  cervical  canal,  784 

feeding  of  infant,  929 

food,  preparation  of,  929 

respiration  of  new-born  infant,  940 
Schultze's  method,  940 
Aseptic  technique  in  obstetric  operations, 

773 
Ash  of  human  milk,  929 
Asphyxia  livida,  939 

neonatorum,  939 

after-treatment  of,  941 
causes  of,  939 
treatment  of,  939 

of  new-born  child,  939 

pallida,  939 
Assimilation  pelvis,  484 
Asthma  in  pregnancy,  262 
Atelectasis  of  new-born  infant,  941 
Atmosphere,  puerperal  sepsis  from,  732 
Atresia  ani  of  new-born,  treatment,  945 

of  cervix  uteri,  obstruction  of  labor  by, 

530. 
of  vagina,  hysterectomy  for,  896 
obstruction  of  labor  by,  535 
surgical  treatment  of,  894 
Atrophy  of  decidua;,  153 
Auscultation,    diagnosis    of    position    of 
fetus  by,  390 
in  diagnosis  of  pregnancy,  203 
Autoclave,  dressing  and  packing  of,  862 
No.  I,  packing  cage  for,  862 
No.  2,  packing  of,  862 
Auto-infection  in  jjuerperal  sepsis,  726 
Auto-intoxication  in  ])regnancy,  263 
Auvard  incubator,  927 
Avortment  instantane,  272 
Avulsion  of  limbs  of  child  in  labor,  937 
Axis-traction  forceps,  808 
apj)lication  of,  S22 


Baby-clothes,  375 

Baby's  basket,  376 

Baccelli's  method  of  treating  tetanus  in 
puerperal  sepsis,  769 

Bacillus  aerogenes  ca])sulalus  in   puer- 
peral sepsis,  724 
colon,  in  puerfjcral  sepsis,  724,  727 
fa'tidus  in  puerperal  sepsis,  724 
Kleb's  Loffler,  in  puerperal  sepsis,  724 
pyocyaneus  in  j)ucr])cral  se])sis,  724 
tubercle,  in  ])ueri>cra!  sejjsis,  724 


Bacteria,   behavior  of,  in  genital  canal, 
726 
capable  of  pjroducing  puerperal  sepsis, 

723 
manner  of  entrance,  into  genital  canal, 

725 
of  vagina,  715-726 
of  vulva,  722 

passage  of,  from  mother  to  fetus,  1 59 
pathogenic,  in  vagina,  in  pregnancy, 

227 
Bacterin  treatment  of  puerperal  sepsis, 

739 
Bag  of  waters,  319 
Baldy's  operation  for  retrodisplacement 

of  uterus,  918 
Ballottement,  204 
Bandl,  ring  of,  182,  392,  593 
Bandl's  operation  for  ureteral  fistula,  890 
Barnes'  bag  in  treatment  of  hematoma, 

665 
Bartholin's  glands,  45 

abscess  of,  obstruction  of  labor  b_\-, 

537 
Basal  decidua,  147 
Basiotribe,  Tarnier's,  845,  846 
Bath,  hot-air,  in  eclampsia,  636 
Battledore  placenta,  141 
Baudeloccjue,  diameter  of,  448 
Baudelocque's  cephalotribe,  843 

method  of  cephalic  version,  414 
Bier's  cups  for  breast,  709 

hyperemic  treatment  of  mastitis,  708 
Binder,  abdominal.  Storm,  921 

for  symphyseotomy,  853,  854 

mammary,  373 

obstetrical,  341 
Bladder,  calculi  in,  obstruction  of  labor 

by,  553 
changes  in,  in  pregnancy,  185 
diseases  of,  in  pregnancy,  25  r 
hemorrhage  from,  after   o])cration  for 

vesicovaginal  fistula,  888 
implantation  of  ureter  into,  for  ureteral 

fistula,  891 
irritability  of,  in  jjregnancy,  251 
treatment,  252 
Blastodermic  vesicle,  78 
Blastomeres,  78 
Blastula,  78 

Blindness  in  ])regnancy,  256 
Blood,     bacteriology    of,     in     pui'rpi'ral 
sepsis,  732 
changes  in,  in  pregnancy,  185,  261 
circulation  of,  in  fetus,  SS 
diseases    as    indiralinn     for    inducing 
abortion,  798 
in  pregnancy,  261 
in  new-born  infant,  925 
maternal,   alterations  in,   as  cause  of 
abortion,  270 
fatal  to  fetus,  175 


958 


INDEX. 


Blood,  washing  of,  treatment  of  puerperal 

sepsis  by,  740 
Blood-clots,      retention      of,      puerperal 

hemorrhage  from,  658 
Blood-pressure,  increasing,  in  eclampsia, 
630  _ 
remedies  to  reduce,  639 
Blood-vessels,    diseases,    in    pregnancy, 

.-59  . 
of  pelvic  organs,  32 
of  uterus,  changes,  in  pregnancy,  180 
Blot's  perforator,  843,  844 
Blunt  hook,  827 
Body  of  Rosenmiiller,  42 
Body-cavity,  79 
Boric  acid  in  aphthae  of  new-born,  946 

in  thrush  of  new-born,  946 
Bossi's  dilator,  791 

Bougies,   graduated,   artificial  dilatation 
of  cervical  canal  by,  795 
Hegar's,  795 
Bowels,  care  of,  after  abdominal  section, 
901 
in  puerperal  state,  371 
movements  of,  in  new-born  infant,  924 
of  child,  injury  of,  in  labor,  938 
Brachial  palsy  from  injury  during  labor, 

933  .  ■         ' 

Brain,  congestion  of,  in  pregnancy,  254 
diseases  of,  in  pregnancv,  254 
inflammatory  diseases  of,  in  pregnancv, 

.   .^54  '  _ 

injury  to,  during  labor,  932 
Braun-Fernwald's  sign  of  pregnancy,  202 
Braun's  cranioclast,  S44 

hook,  849 
Breast-pump,  707 
Breasts,  abnormalities  of,  695 

abscess  of,  709 

absence  of,  693 

areola  of,  in  pregnancy,  194 

caked,  706,  708 

congestion  and  engorgement  of,  704 

developmental  anomalies  of,  693 

diseases  of,  704 

hypertrophy  of,  693 

in  pregnane}',  194,  236 

in  puerperium,  371 
care  of,  371 
changes  in,  360 

inflammation  of,  707 

management  of,  in  puerperium,  371 

massage  of,  705 

sensations  in,  in  pregnancy,  193 

stride  of,  in  pregnancy,  194 

structure  of,  361 

supernumerary,  693 

tumors  of,  711 
Breech,  extraction  of,  824 
by  blunt  hook,  827 
by  fillet,  827 
In'  forceps,  826 


Breech,    extraction  of,    manual  method 
of,  824 
presentation,  419.     See  also  Presenta- 
tion, breech. 
Brim  of  pelvis,  17 

Broad    ligament    of    uterus,    technic    of 
ligaling,  in  salpingo-oophorec- 
tomy,  707 
tumors  of,  enucleation  of,  911 
Broad-ligament  pregnancy,  287 
Bronchi,  diseases  of,  in  pregnancy,  261 
Bronchial  catarrh  in  pregnancv,  261 
Brow  presentation,  416.     See  also  Pres- 
entation, brow. 
Brown  atrophy  of  myocardium  in  preg- 

•  nanc}',  259 
Brown's  ureter-catheter  cvstoscope,  244 
Bruit,  uterine,  203 
Buhl's  disease,  950 
Bulbs  of  vestibule,  45 
■Bylicki's  pelvimeter,  460 


Caffeix  in  eclampsia,  639 

Caked  breasts,  706,  708 

Calcareous  degeneration  of  placenta,  127- 

of  umbilical  cord,  142 
Calcification  of  placenta,  127 
Calculus,  renal,  251 
in  pelvis,-  251 
in  pregnancy,  252 
obstruction  of  labor  by,  553 
Canals  of  Gartner,  41 
Caput  succedaneum,  935 
in  flat  pelvis,  470 
in  justominor  pelvis,  475 
Carcinoma  of  cervix  uteri  in  pregnancy,. 
225     _ 
obstruction  of  labor  by,  545 
puerperal  hemorrhage  from,  659 
of  vagina  in  pregnancy,  231 
of  vulva  in  pregnancy,  233 
sycytiale,  133 
Cardiac  nerve-storms,  262 
Caries  of  pelvis,  504 

of  teeth  in  pregnancy,  237 
Caruncula;  myrtiformes,  45,  213 

enlarged,   obstruction  of  labor   bv, 

538 
Carus,  curve  of,  24 
Casein  of  milk,  929 
Catarrh,  bronchial,  in  pregnancy,  261 
Catarrhal  endometritis,  151 
Catgut,  preparation  of,  782 
Catharis  in  eclampsia,  636 
Catheterization  before  abdominal  section, 

in  puerperal  state,  370 

of  ureters  in  pregnancy,  244 
Celioh}sterectomy,  85 7 

and  celiohvsterotomv,  choice  of,  S60 
Celiotomy  for  ovarian  c\-st  in  labor,  ^^1 


INDEX. 


959 


Celio-uretero-cystostomy     for     ureteral 

fistula,  889,  89 1 
Celio-uretero-ureterostomy    for    ureteral 

fistula,  889 
Cell-membrane,  internal,  of  ovum,  62 
Celloidin  thread,  preparation  of,  782 
Cells,  decidual,  121 

development  of,  144 
Langhan's,  121 
Cellulitis  in  puerperal  sepsis,  754 
Celom,  79 

Centers  of  ossification  as  signs  of  ma- 
turity of  fetus,  92 
Cephalhematoma,  935 
Cephalic  presentation,  390 

explanation  of  frec[uency,  391 
version,  Baudelocque's  method,  414 
Schatz's  method,  414 
Cephalotribe,  Baudelocque's,  843 

Hicks',  845 
Cephalotribes,  846 

Cervical  canal,  artificia.  dilatation  of,  784 
by    anterior    vaginal    hysterot- 
omy, 795 
by  Champetier  de  Ribes'  bag, 

7S4 
by  Edgar's  method,  786 
by  forceps,  787 
by  graduated  bougies,  795 
by  Harris'  method,  786 
by  incisions,  795 

in  non-pregnant  uterus,  795 
in  pregnant  uterus,  795 
by  manual  methods,  786 
by  Pomeroy's  bag,  7S4 
by    vaginal    Cesarean    section, 

795 
by  Voorhees'  bags,  784 
hydrostatic,  784 
instrumental,  787 
in  non-pregnant  uterus,  787 
in  pregnant  uterus,  790 
Wvlic's  method,  789 
fistula,  diagnosis  of,  880 
mvoma  in  jjregnancy,  225 
polyps  in  ];regnancy,  225 
pregnancy  of  Rokitansky,  154 
Cervicitis  in  pregnancy,  225 
Cervix  uteri,   alterations,   in    pregnancy, 
184 
am])utalion  of,  S98 

Hcgar's  method,  898 
appearance   of,    in    [)regnancy,    199, 

201 
atresia  of,  ohslruc  lion  of  labor  by, 

53° 
cancer  of,  in  pregnane)',  225 

obstruction  of  labor  by,  545 
cicatricial  contraction  of,  f)bstruclion 

of  labor  by    531 
circ  ular  detachment  of,  in  hibf)r,  603 
diseases  of,  in  pregnane}-,  225 


Cervix  uteri,  displacement  of,  obstruction 
of  labor  by,  544 
edema  of,  in  pregnancy,  225 
examination  of,  specular,  at  end  of 

puerperium,  382 
injuries  to,  in  labor,  601 
laceration  of,  repair  of,  898 
operations  on,  897 
j  rigidity  of,  obstruction  of  labor  by, 

I  532 

;  Cesarean  section,  855 

extraperitoneal,  861 

for  placenta  pr;evia,  581 

in  eclampsia,  640 

in  labor  with  contracted  pelvis,  528, 

5 -'9  . 
indications  for,  857 
Porro's  method,  857 
postmortem,  856 
Sanger's  method,  858 
upon  living  woman,  856 
vaginal,  artificial  dilatation  of  cervi- 
cal canal  by,  795 
varieties  of,  856 
Cessation    of    menstruation    as    sign    of 
pregnane}^,  191 
without  pregnancy,  192 
Chamljerlen's  vectis,  803 
Champetier  de  Ribes'  bag  for  artificial 

dilatation  of  cervical  canal,  784 
Child,    new-born,    373,   923.     See   also 

New-born  infant. 
Child-bearing    process,    operations    for 
c(jmplications    and    pathological    con- 
serjuences  of,  S62 
Chloasma  in  pregnancy,  194,  266 
Chloral  in  eclampsia,  63S 
in  galactorrhea,  702 
in  inertia  uteri,  442 
in  rigidity  of  cervix  uteri,  532 
Chloroform  in  eclampsia,  636 
in  labor,  331 

in  obstetric  oi)cralions,  783 
Cholcmic  convulsions,  abortion  from,  270 
Cliolera  of  fetus,  162 
Chonrlrofhstrophia  foetalis,  164 
Chorea,  aljorlion  from,  269 
in  pregnancy,  234 
treatment,  255 
Chorio-cpithclioma,  134,  135 
Chorion,  chronic  inflanunalion  of,  119 
des(  riplion  of,   1  10 
dcyelo])iucnl  nf,  1 10 
diseases  of,  i  1  i 
false,  1 10 

fibromyomalous  degeneration  of,  1 19 
frondosum,  1 1 1 
l;eve,  1 1 1 
myxoma  of,  1 14 

relation  of,  lo  syncytial  cancer,  116 
rupture  nf,   1 19 
\illi  of,  I  ID 


960 


INDEX. 


Chorion,    villi    of,    cystic   degeneration, 
III.     See  also  Cystic  degeneration . 
dropsy  of,  in 
Chorionic  vilH,  no 
Chyluria  in  pregnancy.  253 
Cicatrices  of  vagina,  obstruction  of  labor 

by,  534 
Circular  vein  of  placenta,  124 
Circulation  of  blood  in  fetus,  88 
Circulatory  apparatus,  alterations  in,  in 
puerperal  state,  357 

system,  changes  in,  in  pregnancy,  185 
diseases  of,  in  pregnancy,  257 
Claudius  iodine  gut,  783 
Cleft-palate  of  new-born,  944 
Cleidotomy,  849 
Cleveland's  dilator,  788 
Clitoris,  45 

amputation  of,  indications  for,  866 

glans,  45 
Cloaca,  39,  42 
Cocain  for  hemorrhoids,  246 

in  pernicious  vomiting,  241 
Coccvgectomy,  technic  of,  922 
Coccyx,  examination  of,  at  end  of  puer- 
perium,  385 

fracture  of,  in  labor,  620 
Coffee-grounds  vomit  in  melena  neona- 
torum, 952 
Coitional   vagina,   Isaac's  operation  for 
making,  897 
Sneguireff's  operation   for  making, 
897 
Coitus,  time  when  most  likely  to  result  in 

conception,  74 
Colic  of  new-born,  946 
Collargol  in  puerperal  sepsis,  740 
Colloidal  silver  in  puerperal  sepsis,  740 
Colon  bacillus  in  puerperal  sepsis,  724, 

727  _ 

Color  of  milk,  anomalies  of,  704 
Colostrum,  195,  362,  695 

in  pregnancy,  195 
Colostrum-corpuscles  in  milk,  703 
Colovesical  fistula,  877,  879 

diagnosis  of,  880 
Colpitis   emphysematosa   in   pregnancy, 

--9 
Colpocleisis  in  vesicovaginal  fistula,  855, 

886 
Colpohyperplasia  cvstica  in  pregnancy, 

228 
Colpoureterocvstostomv  for  ureteral  fis- 
tula, 889 
Combined  version,  830 

D'Outrepont's  method  of,  831 
Wright's  method  of,  831 
visual  and  touch  examination  in  preg- 
nancy, 201 
Compact  layer  of  uterine  decidua,  147 
Compound  presentation,  563 
treatment,  564  ' 


Conception,  average  date,  after  marriage, 

.  75 

time  when  most  likely  to  occur,  74 
Condyloma,   pointed,  of  vulva,   in   preg- 
nancy, 231 
Congestion  of  brain  in  pregnancy,  254 
Conglutinatio  orificii  uteri  externi,  531 
Conjugate  diameter,  false,  of  spondylo- 
listhetic pelvis,  510 
of  pelvis,  diagonal,  measurement  of, 
452 
by  manual  method,  453 
external,  measurement  of,  448 
of  pelvis,   true,   measurement  of,  452, 

.453  .   .  . 
Conjunctivitis  of  new-born,  946 
Connective  tissue  of  pelvis,  28 

of  uterus,  alterations,  in  pregnancy, 
180 
Constipation  in  pregnancy,  188 

treatment,  242 
of  new-born,  946 
Contracted  pelvis,  flat,  475 

generally,  475 

obliquely,  478 

transversely,  482 

version  in,  828 
Contraction-ring,  182,  392,  593 
Convulsions,  627.     See  also  Eclampsia. 
Cord,  umbilical,  136.     See  also  Umbilical 

cord. 
Cords,  coiling  of,  in  twin  labor,  567 
Corpora  reduplicato,  433 
Corpus  luteum,  64 

lutein  in,  64 

of  menstruation,  65 

of  pregnancy,  65 
Corpuscles,  -accessory,  of  spermatozoon, 

7° 
colostrum-,  in  milk,  703 

Cotyledons,  124 

of  placenta,  124 
Coughing,  abortion  from,  269 
Cows'  milk  compared  to  human,  930 

compostion  of,  930 
Coxalgia,  521 
Coxalgic  -pelvis,  521 
Cranioclast,  844,  846 

Braun's,  844 

Hirst's,  844 

Simpson's,  844 
Craniopagus,  555 
Craniotomy,  842 

instruments  for,  843 

technic  oi,  846 
Cranium,     premature     ossification     of, 

obstruction  of  labor  by,  558 
Crede's  method  of  expressing  placenta, 
343,  435 

ointment  in  puerperal  sepsis,  740 
Cretin  pelvis,  473 
Cretinism,  fetal,  sporadic,  164 


INDEX. 


961 


Cuneiform  hysterectomy,  technic  of,  902 
Cups,  Bier's,  for  breast,  709 
Curve  of  carus,  24 
Cyanosis  of  new-born,  949 
Cystic  degeneration  of  chorion  vilH,  11 1 
clinical  history,  116 
diagnosis,  116 
etiology  and  frequency,  118 
pathologic  anatom)',  114 
stenosis  of  umbilical  vein  asso- 
ciated with,  iiS 
treatment,  iiS 
elephantiasis,  congenital,  of  fetus,  165 
'endometritis,  152 
of  decidua,  152 
Cystitis  in  pregnancy,  252 

septic,  in  puerperal  sepsis,  766 
Cystocele,  obstruction  of  labor  by,  553 

operation  for,  876 
Cystoscope,  Brown's,  244 

Eisner's,  246 
Cystoscopy  of  ureters  in  pregnancy,  244 
Cysts  of  amnion,  109 
of  placenta,  131 
of  umbilical  cord,  142 
ovarian,  complication  of  labor  by,  549 

in  pregnancv,  225 
vaginal,  in  pregnancy,  231 


Davis'  forceps,  806,  808 
Death  of  fetus  as  indication  for  inducing 
abortion,  79S 

causes,  in  fetus  itself,  177 
referable  to  father,  177 

detection,  173 

diagnosis,  211 

effect  on  mother,  172,  624 

habitual,  174 

in  utero,  171 

obstruction  of  labor  bv,  560 
of  mother,  effect  of,  on  fetus,  170,  624 
sudden,  in  labor,  621 
Decapitation,  848 
Decidua,  143 

acute  inflammation  of,  152 

atrophy  of,  153 

basal,  147 

catarrhal  endometritis  of,  151 

cystic  endometritis  of,   152 

diffuse  hyj)erplasia  of,  148,  149 

diseases  of,  148 

epichorial,  147 

Hunlcrian  theory  of  development,  143 

microbic  endometritis  of,   153 

ovular,   147 

])laccntal,   147 

])()l\]K)id  endometritis  of,  149 

purulent  endometritis  of,  153 

reflexa,  145,  147 

serotina,  1 10 

uterine,  147 

61 


Decidua,  uterine,  compact  layer  of,  147 
glandular  layer  ol,  147 
spongy  layer  of,  147 
vera,  147 
Decidual  cells,  121 

development  of,  144 
of  Friedlander,  147 
endometritis,  exanthematous,  153 
hemorrhagic,  153 
purulent  and  microbic,  153 
endometrium,  diffuse  hyperplasia,  148, 

149 
fragments,  retenton  of,  after  labor,  651 
Deciduoma  malignum,  132 
DeciduosarcOma,  132 
Deformities    of    pelvis,    445.     See    also 

Pelvis,  deformities  of. 
Degeneration,    calcareous,    of    placenta, 
127 
of  umbilical  cord,  142 
cystic,  of  chorion  villi,  iii.     See  also 

Cystic  degeneration. 
fibromyxomatous,  of  chorion,  1 19 
myxomatous,  of  placenta,  127 
of  placental  villi,  127 
Delirium  of  fever  in  pregnancy,  257 
temporary,  of  labor,  257 
tremens  distinguished  from  puerperal 
insanity,  257 
in  labor,  257 
Delivery  of  placenta,  342 

postmortem,  624 
Descent  stage  of  labor,  320 
Determination  of  sex,  93 
Deutoplasm  of  ovum,  62 
Deventer's  method    of   delivering    after- 
coming  head,  84 1 
Diabetes,    maternal   effect  of,    on   fetus, 
176 
mellitus  in  pregnancy,  253 
Diagonal  conjugate,  measurement  of,  452 

manual  method,  453 
Diameter  of  Baudelocc|ue,  44S 

of   pelvis,    anteroposterior,    of   outlet, 
measurement  of,  465 
diagonal  conjugate,  measurement  of, 

by  manual  mctliod,  453 
external  conjugate,  measurement  of, 

448 
oblique,   of   inlet,    measurement   of, 

462 
transverse,  measurement  of,  460 
of  outlet,  measurement  of,  462 
true    conjugate,     measurement    of, 

452,  45.^ 
Diameters  of  fetal  lii'ad,  normal,  92 

of  pelvis,  22 
Diajjliorcsis  in  eclampsia,  636 
Diarrhea  in  i)regnancv,  treatment,  242 
Diastasis  of  abdominal  nnisi  les  in  ial)or, 
620 
in  ]iucT])eral  state,  686 


962 


INDEX. 


Diastasis  of  recti  muscles,  operative  treat- 
ment, gig 
Webster's  operation  for,  g2o 

Dicephalus,  555 
birth  of,  555,  558 

Diet  in  pregnancy,  189 
in  puerperal  state,  368 
regulation  of,  in  pregnancy,  189 

Digestion  in  new-born  infant,  924 

Digestive  tract,  changes  in,  in  pregnancy. 

Dilatation,  artificial,  of  cervical  canal,  784 

instrumental,  of  cervical  canal,  787 

stage  of  labor,  320 
Dilator,  Bossi's,  791 

Cleveland's,  788 

Hegar's,  795 

Hirst's  (J.  C),  7go 

Schatz's,  789 
Dimensions  of  fetal  head,  92 
Diphtheria,  bacillus  of,  in  puerperal  sep- 
sis, 724 

in  puerperal  state,  681 

relation  of,  to  puerperal  sepsis,  771 
Diprosopus,  craniotomy  for,  560 
Direction  of  presenting  part,  anomalies 

of,  403 
Discus  proligerus,  61 
Dislocation  in  fetus,  166 

of  kidney  in  pregnancy,  250 
in  puerperal  state,  691 

of  thigh-bones,  effect  of,  on  pelvis,  522 
Displacements  of  uterus,  obstruction  of 

labor  by,  538 
Dissecting  metritis  in  puerperal  sepsis, 

754 
Distortion  of  head  during  labor,  933 
Doderlein's  lochial  tube,  730 

tube,  Nicholson's  modification  of,  731 
Double  promontory,  468 

uterus,  obstruction  of  labor  by,  530 
D'Outrepont's     method     of     combined 

version,  831 
Drain,  Wylie's,  for  artificial  dilatation  of 

cervical  canal,  789 
Drainage  after  abdominal  section,  901 
Dressings  and  packing  of  autoclave,  862 
Dropsy  of  amnion,  103 

of  chorionic  villi,  in 
Dry  labor,  332,  570 
Ductus  arteriosus,  89 

omphalicus,  137 

venosus,  88 
Dudley's  operation  for  ureteral  fistula, 

890' 
Diihrssen's  method  of  artificial  dilatation 

of  cervical  canal,  795 
Dulness  on   percussion  of  abdomen  in 

pregnancy,  203 
Duration  of  pregnancy,  estimation,  210 
Dwarf  pelvis,  472,  473 
Dystocia,  439 


Dystocia  due  to  disease,  627 
Dysuria     in    retroflexion    of    pregnant 
uterus,  216 

Eclampsia,  628 
abortion  from,  269 
accouchement  force  in,  640 
anesthetization  in,  636 
caft'ein  in,  639 
catharsis  in,  636 
causes,  628 

Cesarean  section  in,  640 
chloral  in,  638 
chloroform  in,  636 
diaphoresis  in,  636 
differential  diagnosis,  632 
effect  of,  on  fetus,  170 
frequency,  630 
hot-air  bath  in,  636 
in  labor,  639 
increased  blood-pressure  in,  remedies 

to  reduce,  639 
increasing  blood-pressure  in,  630 
morphin  in,  638 
nitrite  of  amyl,  639 
nitrogh^cerin  in,  639 
obstetrical  treatment,  639 
oxygen  in,  639 
parathyroid  extract  in,  639 
pathology,  632 
pilocarpin  in,  639 
portable  sweat  cabinet  in,  636 
prognosis,  633 

puncture  of  membranes  in,  639 
remedies  to  reduce  blood-pressure  in, 

639 
scheme  of  treatment,  641 

symptoms,  630 

thyroid  extract  in,  639 

treatment,  635 

urine  in,  632 

venesection  in,  637 

veratrum  yiride  in,  638 

wet-pack  in,  636 
Ectoderm,  78,  98 

Ectopic  pregnancy,  284.     See  also  Extra- 
uterine pregnancy. 
Eczema  of  nipples  in  pregnancy,  236 
Edema  of  cervix  uteri  in  pregnancy,  225 

of  genitals  after  labor,  64g 

of  glottis  in  pregnancy,  261 

of  placenta,  127 

of  vulva  in  pregnancy,  234 
obstruction  of  labor  by,  537 
Edgar's  method  of  artificial  dilatation  of 

cervical  canal,  786 
Egg-cords,  61 

Ehrenfest-Neumann     kliseometer,     463, 
464 

pelvigraph,  463,  464 
Elastic  tissue  of  uterus,  changes,  in  preg- 
nancy, 180 


INDEX. 


963 


Electricity   in   postpartum    hemorrhage, 

589  ; 

Elephantiasis,  congenital  cystic,  165 
of  fetus,  165 
of  vulva,  obstruction  of  labor  by,  535 
treatment  of,  867 
Eisner's  cvstoscope,  246 
Embolism,  pulmonary,  in  labor,  623 

in  pregnancy,  262 
Embryo,  death  of,  as  an  indication  for 
inducing  abortion,  79S 
development  of,  80 
in  first  month,  80 
in  second  month,  84 
in  third  month,  85 
Embryonal  area,  78 
Embryotomy,  842 

instruments  for,  843 
Emmet's    operation    for    lacerations    of 

posterior  wall  of  vagina,  868-871 
Emotion  as  cause  of  puerperal  hemor- 
rhage, 657 
death  from,  in  labor,  623 
maternal,  influence  of,  on  fetus,  169 
Emotional  fever  in  puerperal  state,  665 
Emphysema  in  pregnancy,  261 

subcutaneous,  in  labor,  621 
Endocervicitis  in  pregnancy,  225 
Endochorion,  iii 

Endocolpitis  in  puerperal  sepsis,  753 
Endometritis,  catarrhal,  151 

chronic,  as  cause  of  death  of  fetus,  175 
cystic,  152 

decidual,  exanthematous,  153 
hemorrhagic,  153 
purulent  and  microbic,  153 
decidualis  polyposa,  149 

tuberosa,  149 
in  puerperal  sepsis,  753 
microbic  decidual,  153 
placentaris,  128 
gummosa,  128 
polypoid,  149 

of  dccidua,  149 
purulent  decidual,  153 
tuberculous,  153 
Endometrium,   decidual,    diffuse   hyper- 
plasia, 148,  149 
hyperplastic  inflammation  of,  148 
involution  of,  352 
English  forcei)S,  S05 
Enterocele,  vaginal  obstruction  of  labor 

'3y>  552 

Knterovesical  fistuUj  877,  878 

diagnosis  of,  880 
Entoderm,  78,  98 
E])ichorial  decidua,  147 
E[)ilcpsy,  abortion  from,  270 

in  pregnancy,  255 
Episiotomy,  334 
Epistaxis  in  parturition,  261 

in  pregnancy,  261 


Epoophoron,  42 

Ergotin  in  postpartum  hemorrhage,  587 

Erysipelas  in  puerperal  state,  679 

of  fetus,  160 

relation  of,  to  puerperal  sepsis,  771 
Erythematous  rashes  in  puerperal  state, 

678 
Ether  in  labor,  331 
Evisceration,  849 
Evolution,  spontaneous,  432 
Exanthemata  in  puerperal  state,  674 

of  new-born,  944 
Exanthematous    decidual    endometritis, 

153 
Exochorion,  112,  114 
Exostoses  of  pelvis,  498 
Expulsion,  forces  of,  392 
excessive  power  of,  444 
of  gravid  uterus,  218 
stage  of  labor,  320 
Exsection  of  vulvar  nerves,  865 
Extension  of  fetal  head,  anomalies  of,  403 
in  face  presentations,  410 
in  labor,  398 
External    conjugate,    measurement     of, 
448 
genitals,  development  of,  42 
Extramedian  engagement  of  head,  472 
Extraperitoneal  Cesarean  section,  861 
Extra-uterine  pregnancy,  284 
advanced,  treatment,  308 
changes  in  uterus  and  vagina  in,  287 
classification,  285 
clinical  history,  286 
diagnosis,  304 
etiology,  285 
frequency,  284 
prognosis,  305 
symptoms,  303 
terminations,  295 
treatment,  306 
Eves,  diseases  of,  in  pregnancy,  256 

failing  of,  in  pregnane)-,  256 
Eyesight  in  new-born  infant,  925 


Face,  appearance  of,  in  pregnancy,  194 
of  fetus,  injuries  of,  during  labor,  936 
presentation,  409.     See  also  Presenta- 
tion, jdce. 

I-"allopian  tubes,  anatomy,  53 

l''alse  corpus  luteum,  65 

Farabcuf's  jjclyimctcr,  459 

Fascia,  ])elvic,  2S 

Fat  of  human  milk,  c)2() 

Fatty  degeneration  of  lieari  in  pregnancy, 

250 
Fec<ling  of  new-born  iiifani,  929 

artificial,  929 
Female  pronucleus,  74 

sexual  organs,  deyel<)[)ment,  30 
Femora,  Kixation  of,  effect  on  ])elyis,  522 


964 


INDEX. 


Ferguson's  operation  for  urinary  fistula, 

884 
Fertilization  of  ovum,  73 
Fetal  body,  394 

manner  in  which  uterine  muscle  acts 
on,  393 
cretinism,  sporadic,  164 
head,  dimensions,  92 

large,  obstruction  of  labor  by,  558 

possible  presentations  of,  395 

structure  of,  394 
heart  sounds  in  pregnancy,  203 
mortality,  155 
movements,  193 

auscultation,  204 

in  pregnancy,  193 
palpation,  201 
pelvis,  476 
syphilis,  155 

causes,  155 

diagnosis,  157 

manifestations,  156 

prognosis,  156 

treatment,  158 

Wegner's  sign,  157 
traumatism,  166 
Fetation,  multiple,  95 

abortion  in,  96 

acardia  in,  96 

foetus  papyraceus  in,  96 

frequency  of,  95 

hydramnios  in,  96 

placenta  in,  96 
Fetometry,  antepartum,  465 

Hirst's  method,  466 

Miiller's  method,  465 

Ferret's  method,  466 

Stone's  method,  466 
Fetus,  accidents  to,  625 
achondroplasia,  164 
alterations  in  maternal  blood  fatal  to, 

175 
amorphous,  143 
anasarca  of,  164 
ankylosis  of,  166 
articular  rheumatism  of,  162 
causes  of  death,  in  itself,  177 
cholera  of,  162 
chondrodystrophia,  164 
circulation  of  blood  in,  88 
conditions  of    mother    which    injure, 
168 

of  uterus  which  interfere  with  de- 
velopment, 175 
congenital  cystic  elephantiasis,  165 
death  of,  detection  of,  173 

diagnosis  of,  211 

effect  of,  on  mother,  172 

from  causes  in  itself,  177 
referable  to  father,  177 

habitual,  174 

in  utcro,  171 


Fetus,  death  of,  indication  for  induction 
of  abortion,  798 
obstruction  of  labor  by,  560 
development  of,  80 
in  eighth  month,  87 
in  fifth  month,  86 
in  first  month,  80 
in  fourth  month,  85 
in  ninth  month,  87 
in  second  month,  84 
in  seventh  month,  86 
in  sixth  month,  186 
in  tenth  month,  87 
in  third  month,  85 
diagnosis  of  life  or  death  of,  211 

of  position,  by  abdominal  palpation, 

389 
by  auscultation,  390 

of  sex  of,  213 
diseases  of,  155 

obstruction  of  labor  by,  560 
dislocations  in,  166 
effect  of  death  of  mother  upon,  624 
of  excess  of  urea  in  maternal  blood 
upon,  176 
erysipelas  of,  160 
fractures  of  bones  of,  in  utero,  165 
habitual  death  of,  174 

diagnosis  of  cause  of,  178 
preventive  treatment  of,  179 
infectious  diseases,  other  than  syphilis, 

159 
influence  of  chronic  diseases  of  mother 

on,  176 
poisoning  of  mother  on,  176 
of  death  of  mother  on,  170 
of  eclampsia  on,  170 
of  icterus  gravidarum  on,  170 
of  maternal  diabetes  on,  176 
emotions  on,  169 
fever  on,  168 
nephritis  on,  176 
intestinal  invagination  of,  166 
intra-uterine  amputations  in,  166 
luxations  in,  166 

lymphangioma  of,  obstruction  of  labor 
'  by,  559 
malaria  of,  162 
malformations  of,  obstruction  of  labor 

by,  558 

mature,  91 

general  appearance  of,  92 

length  of,  92 

weight  of,  91 
measles  of,  160 
myxoma  of,   obstruction  of  labor  by, 

559 
non-infectious  diseases  of,  163 
overgrowth  of,  obstruction  of  labor  by, 

553 
papyraceus,  96 
pneumonia  of,  163 


INDEX. 


965 


Fetus,  position  of,  abdominal  palpation 
to  determine,  3S9 
auscultation  to  determine,  390 
rachitis  of,  163 
recurrent  fever  of,  162 
sacral  teratoma  of,  obstruction  of  labor 

by,  559 
scarlatina  of,  .160 
septicemia  of,  162 
sex  of,  diagnosis  of,  213 
signs  of  maturity  of,  91 
small-pox  of,  159 
syphilis     of,      155.     See     also     Fetal 

syph  His. 
syphilitic  infection  of,  155 
temperature  of,  in  utero,  90 
traumatism  of,  166 
tuberculosis  of,  161 
tumors  of,  obstruction  of  labor  by,  558 
typhoid  fever  of,  162 
vaccination  of,  159 
variola  of,  159 
yellow  fever  of,  162 
Fever  in  puerperal  state,  emotional,  665 
from  cerebral  disease,  670 
from  constipation,  668 
from  exposure  to  cold,  668 
from  reflex  irritation,  668 
from  sun-stroke,  671 
non-infectious,  665 
persistence  or  exacerbation  of,  672 
syphilitic,  671 
with  eclampsia,  670 
maternal,  influence  of,  upon  fetus,  168 
recurrent,  of  fetus,  162 
Fibroids  of  uterus  in  puerperal  state,  658 
obstruction  of  labor  by,  545 
puerperal  hemorrhage  from,  65S 
Fibroma  of  uterus  in  pregnancy,  223 
Fibromyoma  of  round  ligament  in  groin 
in  pregnancy,  225 
of  uterine  muscle  in  pregnancy,  223 
Fibromyxomatous   degeneration  of  cho- 
rion, T19 
Fillet-carrier,  825,  826 

extraction  of  breech  by,  826 
Fimbria  of  oviduct,  53 
Finger  nails,  loosening  of,  in  prcgnancv, 

266 
Fistula    between    genital     and    urinary 
canals,  875 
cervical,  diagnosis  of,  880 
colovesical,  877,  879 

diagnosis  of,  880 
enterovesicai,  877,  878 

fiiagnosis  of,  880 
following     pressure-necrosis    in     pro- 

longcfi  labor,  877 
genito-urinary,  in  labor,  619 
perineovaginal,  treatment  of,  864 
ureteral.     See  Ureteral  fistula. 
uretero-uterine,  877 


Fistula,  ureterovaginal,  877 
urethral,  877 
urinary,  875 

classification  of,  877 
uterovesical,  877,  87S 
uterovesicovaginal,  877 
vesicovaginal,  877 

colpocleisis  in,  885,  886 

diagnosis  of,  879 

Ferguson's  operation  for,  885 

in  labor,  619 

incontinence  of  urine  after  operation 

for,  887,  888 
intravesical  hemorrhage  after  opera- 
tion for,  888 
treatment  of,  881 

after  operation  for,  888 
operative,  883 
vesico vestibular,  877 
Flat  pelvis,  non-rachitic,  475 
simple,  466 
rachitic  pelvis,  486 
Fleming's  operation  for  making  artificial 

vagina,  895 
Flexion  of  fetal  head,  397 

abnormalities  of,  402 
Fcetus  papyraceus,  96 
Food-yolk  of  ovum,  62 
Foramen  ovale,  89 
Forceps,  800 

application  of,  811 

artificial  dilatation  of  cervical  canal  bv, 

axis-traction,  application  of,  822 

Davis',  806,  808 

dilatation  of  cervical  canal  by,  787 

English,  805 

French,  805 

German,  805 

Hermann's,  807 

Hirst's,  806 

historical  sketch  of,  800 

Hodge's,  806 

in  after-coming  head,  841 

in  breech  presentation,  826 

in  labor  with  contracted  j)elvis,  527 

in  occipitopostcrior  position,  821 

in  transverse  positions  of  head,  821 

indications  for  aj)plication  of,  809 

introduction  of,  811 

Levret's,  804 

locking  of.  Si 7 

mortality  from,  822 

Palfyn's,  803 

position  for,  81 1 

Poulet's,  808 

])rc])arations  for  ap])lication  of,  Sii 

Sim])son's,  S06,  807 

Smeilie's,  802,  804 

sterilization  of,  81  r 

Tarnier's  axis-traction,  808 

traction  on,  820 


966 


INDEX. 


Forceps,  uses  and  functions  of,  809 
Forces  of  expulsion,  392 

of  labor,  anomalies  of,  439 

of  resistance,  392 
Fossa  navicularis,  44 
Fourchet,  44 
Fowler's    position    after    operation    for 

diffuse  suppurative  peritonitis,  758 
Fracture  in  utero,  165 

of  coccyx  in  labor,  620 

of  limbs  of  child  during  labor,  937 

of  pelvic  bones  in  labor,  620 

of  pelvis,  501 

of  sacrococcygeal  joint  in  labor,  620 

of  skull  during  labor,  933 
French  forceps,  805 

method  of  performing  svmphvseotomv, 

.854 
Friedlander,  decidual  cells  of,  147 
Fritsch's  method  of  treating  postpartum 

hemorrhage,  589 
Fundus  uteri,  height  of,  as  an  indication 

of  duration  of  pregnancy,  211 
Funic  soulBe,  204 

Funis,  136.     See  also  Umbilical  cord. 
Funnel-shaped    pelvis,    476.      See    also 

Pelvis,  funnel-shaped. 
Furuncles  of  new-born,  947 


Galactocele,  711 

Galactorrhea,  701 

Galbiati's  knife  for  cutting  symphvsis, 

851 
Gangrene  of  vulva,  obstruction  of  labor 

by,  537 
puerperal,  763 
Gartner's  canals,  41 
Gas  bacillus  in  puerperal  sepsis,  724 
Gastro-intestinal    hemorrhage    in    new- 
born, 951 
Gauze  pad  for  abdomen,  781 
Gavage  of  premature  infants,  927 
Gelatin  of  Wharton,  137 
Generative  organs,  nerves  of,  32 
Genital  and  urinary  canals,  fistula  be- 
tween, 875 
canal,  tumors  of,  obstuction  of  labor 

by,  545 

cord,  40 

eminence,  42 

tract,    wounds   in,    puerperal    hemor- 
rhage from,  659 
Genitalia,  diseases  of,  215 

external,  development  of,  42 

internal,  development  of,  39 
Genito-urinary  fistula  in  labor,  619 
German  forceps,  805 
Germinal  spot  of  ovum,  62 

vesicle  of  ovum,  62 
Germ-yolk  of  ovum,  62 
Gestation,  17.     See  also  Pregnancy. 


Gingivitis  in  pregnancy,  237 
Glands  of  Montgomery,  195,  362 

inflammation  of,  704 
Gland-space,  61 

Glandular  layer  of  uterine  decidua,  147 
Glans  of  clitoris,  45 
Glottis,  edema  of,  in  pregnancy,  261 
Gloves,  rubber,  778 

sterilization  of,  780 
Glycosuria  in  puerperal  state,  359 
Goiter  in  pregnancy,  259 
Gonococcus  in  puerperal  sepsis,  724,  727 
Gonococcus-infection  in  pregnancy,  227 
Gonorrhea  in  puerperal  state,  685 
Gonorrheal  stomatitis  of  new-born,  946 
Goodell's  rule  of  pregnancy,  201 
Graafian  follicle,  55 

development  of,  61 

rupture  of,  61 
Graduated  bougies,  dilatation  of  cervical 

■  canal  by,  795 
Graves'  disease  in  pregnane}^,  259 
Gravid  uterus.     See  also  Pregnant  uterus. 
Gum  of  new-born,  923 


Habitual  death  of  fetus,  174 
diagnosis  of  cause,  178 
preventive  treatment,  179 
Hands,  cleansing  of,  for  obstetric  opera- 
tions, 778 
Harelip,  treatment  of,  944 
Harris-Dickinson  pelvimeter,  449 
Harris'  method  of  artificial  dilatation  of 

cervical  canal,  786 
Head  crushers,  846 

extramedian  engagement  of,  472 
fetal,  dimensions,  92 

efl'ects  of  flat  pelvis  on,  469 
possible  presentations,  395 
structure  of,  394 
seizers,  846 
Hearing,  disturbances  of,  in  pregnancy, 
256 
in  pregnancy,  256 
Heart  afi'ections  of  new-born,  949 
changes  in,  in  pregnancy,  186 
disease  in  labor,  643 
diseases  of,  in  pregnancy,  257 
prognosis,  258 
treatment,  258 
of  new-born  infant,  926 
sounds,  fetal,  in  pregnancy,  ausculta- 
tion of,  203 
Heart-failure  in  labor,  621 
Heart-muscle,  diseases,  in  pregnancy,  259 
Heat-stroke  in  puerperal  state,  671 
Hebosteotomy,  S54 
Hebotomy,  854 

Hegar's  dilators  or  bougies,  795 
method  of  amputating  cervix,  898 
sign  of  pregnancy,  201 


INDEX. 


96 


Hematocele,  ante-uterine,  302 
from  tubal  pregnancy,  302 
retro-uterine,  302 
Hematoma   from    ruptured   tubal   preg- 
nancy, 302 
of  cord,  143 

of  vagina,  obstruction  of  labor  by,  534 
polypoid,  of  uterus,  149 
puerperal,  659 

clinical  history  of,  661 
diagnosis  of,  661 
etiology  of,  661 
hemorrhage  from,  658,  659 
prognosis  of,  663 
situation  of,  660 
size  and  form  of,  660 
treatment  of,  664 
rupture  of,  in  labor,  623 
Hematuria  in  pregnancy,  253 

in  puerperal  state,  690 
Hemidrosis  of  new-born  infant,  949 
Hemiplegia  in  puerperal  state,  692 
Hemophilia  of  new-born,  949 
Hemoptysis  in  pregnancy,  262 
Hemorrhage,  accidental,  572,  583 
complicating  labor,  572 
from  laceration  of  cervix,  601 
from  umbilicus,  951 
gastro-intestinal,  in  new-born,  951 
in  abortion,  272 
in  placenta  praevia,  575 
in  third  stage  of  labor,  prevention  of, 

339 
intravesical,  after  operation  for  vesico- 
vaginal fistula,  888 
placental,  130 
postpartum,  585 

abdominal  binder  in,  587 

auto-infusion  in,  591 

causes,  585 

compression  of  uterus  in,  587 

diagnosis,  586 

electricity  in,  589 

ergotin  in,  589 

Fritsch's  method  of  treating,  589 

from  relaxation  of   uterine  muscle, 

intravenous   injection    of   salt   solu- 
tion in,  390 
Monscl's  solution  in,  589 
mor[)hin  in,  591 
rectal  injection  f)f  salt  solution  in, 

590 
symptoms,  586 
tampon  in,  i;S8 
transfusion  of  blood  in,  592 
treatment,  587 
puerperal,  649 

from  cancer  of  cervix,  659 
from  dislodgment  of  thrombi,  657 
from  displacements  of  uterus,  653 
from  emotional  causes,  657 


Hemorrhage,   puerperal,    from   fibroids, 
658 
from  hematoma,  658,  659 
from  ])elvic  engorgement,  658 
from  relaxation  of  uterus,  658 
from   retained   placenta  and   mem- 
branes, 649 
from  retention  of  blood-clots,  658 
from  wounds  in  genital  tract,  659 
unavoidable,  572,  583 
uterine,    as    indication    for    inducing 
abortion,  798 
Hemorrhagic  decidual  endometritis,  153 
Hemorrhoids  in  pregnancy,  244 
vesical,'  252 

in  pregnancy,  252 
Hemothorax    of    child    from    injury    in 

labor,  939 
Hensen's  node,  78 
Heredity,  function  of,  in  labor,  314 
Hermann's  forceps,  807 
Hernia  of  placenta,  438 

of    pregnant    uterus,    obstruction    of 

labor  by,  539,  540 
umbilical,  142 

of  new-born,  944 
vaginal,  obstruction  of  labor  by,  552 
Hernial     protrusion,     pregnant     uterus 

forming  part,  222 
Herpes  gestationis,  265 
in  pregnancy,  265 
Hicks'  cephalotribe,  845 
Hirst's  canvas  binder  for  symphyseotomv, 

853 
cranioclast,  844 
double  tenacula,  788 
forceps,  806 
knife  for  cutting  subpubic  ligament, 

851 
method  of  antepartum  fetometry,  466 
of  jiand  and  skin  cleansing,  779 
of  inducing  abortion,  798 
operating  table,  775 
operation  for  inversion,  615 
pelvimeter,  457 
(J.  C.)  dilator,  790 
Hodge's  forceps,  806 

scissors,  843 
Holmes'  uterine  tul)e  and  packer,  589 
Iloloblastic  ovum,  62 
Hook,  blunt,  827 
Braun's,  S49 
Ramsbotham's,  849 
Hospital  operating  room,  773 
Hot-air  bath  in  eclampsia,  636 
House,  ])rivale,  preparation  for  al)domi- 

nal  section  in,  S99 
Human  milk  as  food,  929 

com[)arcfl  with  cows'  milk,  930 
constitution  of,  929 
Hydatifiiform  mole,  ill 
Hydramnios,  103 


968 


INDEX. 


Hydramnios,  acute,  io6 

diagnosis  of,  io6 

differentiation  of,  from  ascites,  107 
from  ovarian  cyst,  107 
from  twin  pregnancy,  107 

etiology  of,  103 

frequency  of,  103 

from  abnormal  pressure  in  blood- 
vessels of  cord,  104 

from  amnion  itself,  105 

from  both  fetal  and  maternal  sources, 

^°5  . 

from  deficient  absorption  of  liquor 
amnii,  106 

from  excessive  secretion  of  fetal  urine, 
104 

from  fetal  skin,  105 

in  multiple  fetation,  96 

of  fetal  origin,  103 

of  maternal  origin,  103 

symptoms  of,  106 

treatment  of,  107 
Hydrencephalocele,  557 
.  obstuction  of  labor  by,  559 
Hydroamnion,  103 
Hydrocephalus,  560 

diagnosis  of,  560 

treatment  of,  561 
Hydronephrosis  in  pregnancy,  251 
Hydrops  tubae  profluens,  310 
Hydrorrhea  gravidarum,  310 
Hydrostatic  dilatation  of  cervical  canal, 

784 
Hymen,  45 

imperforate,  treatment  of,  864 

resisting,  treatment  of,  864 

unruptured,   obstruction  of  labor  by, 

534 
Hyperemesis  gravidarum.    See  Vomiting, 

pernicious. 
Hyperlactation,  700 
Hyperleukocytosis,  artificial,  in  treatment 

of  puerperal  sepsis,  739 
Hyperplasia,  diffuse,   of  decidual   endo- 
metrium, 148,  149 
Hypertrichosis  in  pregnancy,  199 
Hypertrophy,  localized,  of  cord,  143 

of  breasts,  693 

of  non-pregnant  half  of  uterus  bi- 
cornis  or  didelphys,  obstuction  of 
labor  by,  548 

polypoid,    of   vaginal     mucous   mem- 
brane in  pregnancy,  229 
Hypodermatoclysis  in  puerperal  sepsis, 

740 
Hypodermoclysis,  591 
Hypoplastic  pelvis,  473 
Hysterectomy,  combined,  technic  of,  904 

cuneiform,  technic  of,  902 

for  atresia  of  vagina,  896 

for  puerperal  sepsis,  746 

partial,  technic  of,  902 


Hysterectomy,  technic  of,  901 

vaginal,  technic  of,  904 
Hysteria  in  pregnancy,  255 
Hysterical  convulsions,  abortion  in,  270 
Hysteromyomectomy,  abdominal,  911 

vaginal,  technic  of,  899 
Hysterotomy,  vaginal,  anterior,  artificial 

dilatation  of  cervical  canal  by,  795 


Icterus   gravidarum,    influence   of,   on 
fetus,  170 
of  new-bqrn,  949 
Iliopsoas  muscle,  26 
Imperforate  hymen,  treatment  of,  864 

rectum  of  child,  945 
Impetigo  herpetiformis,  264 

in  pregnancy,  264 
Impregnation,  changes  in  -ovum  follow^- 
.  ing,  78 

time  when  most  likely  to  occur,  74 
Incarceration  of  pregnant  uterus,    216, 
218 
treatment,  219 
Incontinence  of  urine  after  operation  for 
vesicovaginal  fistula,  887,  888 
in  pregnancy,  252 
in  puerperal  state,  691 
Incubation,  926 
Incubator,  Kny-Scheerer,  927 
Indagation,  380 
Indigestion  in  pregnancy,  242 
Induction    of    abortion,    797.     See    also 
Abortion,  induction  oj. 
of  premature  labor,  799 
Inertia  uteri,  439 

diagnosis  of,  441 
etiology  of,  439 
treatment  of,  442 
Infant,    new-born,    373,    923.     See   also 

New-born  infant. 
Infarcts,  placental,  127 
Infectious  diseases  in  pregnancy,  263 
fevers,  relation  of,  to  puerperal  sepsis, 
769 
Inflammation,  acute,  of  decidua;,  152 
adhesive,    in    formation    of    amniotic 

bands,  108 
chronic,  of  chorion,  119 
diffuse  hyperplastic,  of  decidual  endo- 
metrium, 148 
peri-uterine,  in  pregnancy,  235 
Influenza  in  pregnancy,  263 
Infundibulo-pelvic  ligament,  56 
Inguinal  colotomy  for  atresia  ani  of  new- 
born, 945 
glands,  removal  of,  indications  for,  866 
technic  of,  911 
Injuries  of  child-birth,  treatment  of,  64S 
of  pregnancy,  266 
to  infant  during  labor,  932 
Inlet  of  pelvis,  iS 


INDEX. 


969 


Insanity  in  pregnancy,  256 
causes  of,  exciting,  256 

predisposing,  256 
diagnosis  of,  257 
preexisting,  257 
symptoms  of,  256 
time  of  occurrence,  257 
Insemination,  67 
Insertio  velamentosa,  141 
Insolation  in  puerperal  state,  671 
Instrumental  dilatation  of  cervical  canal, 

787 
Instruments  in  obstetric  operations,  783 
Insufflation  in  asphyxia  neonatorum,  940 
Internal  cell-membrane  of  ovum,  62 
Interstitial  cells  of  ovary,  55 
pregnancy,  284 

abdominal  section  for,  307 
clinical  history,  291 
svmptoms,  304 
terminations,  299 
Intestinal  invagination  in  fetus,  166 
Intestines,  diseases  of,  in  pregnancy,  242 

in  pregnancy,  242 
Intraperitoneal  abscess,  abdominal  sec- 
tion for,  744 
Intra-uterine  amputations,  166 

diseases  as  an  indication  for  inducing 
abortion,  798 
Intussusception  of  new-born,  947 
Invagination,  intestinal,  in  female,  166 
Inversion  of  uterus  in  labor,  611.      See 

also  Uterus,  inversion  of. 
Involution  of  uterus,  348,  367 
abnormalities  of,  644 
adnexa  in,  353 

changes  in  blood-vessels  in,  352 
in  muscle-fibers  in,  349,  350 
endometrium  in,  352 
ergot  for,  368 
Irritable  uterus  as  cause  of  abortion,  268 
Isaac's  operation  for  coitional  vagina,  897 
Ischiopagus  parasiticus,  555 
Ischiopubiotomy  in  oblicjuely  contracted 

pelvis,  482 
Ischiorectal  abscess  in  puerperal  sepsis, 

769 
Italian  method  of  performing  symph)-s- 
eotomv,  850 


JANICEPS,   556 

Jaundice  in  pregnancy,  242 

of  new-born,  949 
Johnson's  sign  in  pregnancy,  199,  201 
Joints,  pelvic,  ankylosis  of,  504 
relaxation  of,  504 
after  labor,  7 1 1 
suppuration  of,  769 
syntosis  of,  504 
sacrococcygeal,  ankylosis  of,  504 
sacro-iliac,  rupture  of,  in  labor,  619 


Joints,  sacro-iliac,  synostosis  of,  504 
Jorisenne's  sign  of  pregnancy  186 
Justomajor  pelvis,  483 
Justominor  pelvis,  472.     See  also  Pelvis, 

jitslomiiior. 
Juvenile  pelvis,  472 


Karyokinesis  in  ovum,  62 
Kidney  breakdown  as  an  indication  for 
inducing  abortion,  797 
diseases  of,  in  pregnancy,  246 
dislocation  of,  in  labor,  691 
in  pregnancy,  250 
in  puerperal  state,  691 
in  puerperium,  691 
in  puerperal  state,  690 
of  pregnancy,  246 

ditferential  diagnosis,  from  nephritis, 

248 
etiology,  247 

frequency  and  course,  247 
pathology,  247 
symptoms,  247 
treatment,  247 
palpation  of,  at  end  of  puerperium,  385 
pelvis  of,  diseases,  in  jjregnancy,  250 
Klebs-Loffler  bacillus  in  puerperal  sep- 
sis, 724 
Kliseometer,  Neumann-Ehrenfest,  463 
Knots  of  umbilical  cord,  138,  140 
Kny-Scheerer  incubator,  927 
Krause's  method  of  inducing  premature 

labor,  799 
Kvphoscoliosis,  519 
Kyphoscoliotic  pelvis,  519 
Kyphosis,  511 

lumbosacral,  512 
Kvphotic  pelvis,  511.     See  also  Pelvis, 
kyphotic. 


Labia,  agglutination  of,  treatment,  865 
amputation  of,  indications  for,  866 
in  labor,  322 
majora,  43 

varices  of,  in  ])rcgnancy,  231 
minora,  44 

puncture  of,  for  edema  of  vulva,  234 
Labor,  312 

abdominal  palpation  in,  3.S8 

accidents  of,  623 

action,  a])pcaran(c,  and  condition  of 

woman  in,  318 
anesthetics,  329 
armamentarium  for,  325 
bed  in,  32() 

cajjut  succcdancum  in,  935 
causes  of,  313,  314 
chloroform  in,  331 
circular  detachment  of  cervix  uteri  in, 

603 


970 


INDEX. 


Labor,  clinical  phenomena,  317 

complicated  by  accidents  and  diseases, 

572 

by  heart  disease,  643 

by  hemorrhage,  572 

by  pneumonia,  642 

by  typhoid  fever,  642 
contraction  of  uterus  after,  method  of 

securing,  340 
contractions  of  uterine  muscle  in,  317 
decapitation  of  fetus  during,  936 
deficient  power  of  uterine  muscle  in, 

439.     See  also  Inertia  uteri. 
definition  of,  313 
delirium  tremens  in,  257 
descent  of  uterus  in,  315 
diagnosis  of,  315 

diastasis  of  abdominal  muscles  in,  620 
dislocation  of  kidney  in,  691 
distortion  of  head  during,  933 
dry,  332,  570 
duration  of,  317 
eclampsia  in,  639 

embolism  of  pulmonary  artery  in,  623 
ether  in,  331 
:    examination  of  patient  in,  326 
expulsion  of  trunk  in,  402 
expulsive  forces  of,  excessive  power  of, 

444 
first  stage,  320 

anesthetics  in,  330 
management,  328 
pain  in,  329 
forces  involved  in,  392 
anomalies  of,  439 
fracture  of  coccyx  in,  620 

of  limbs  of  child  during,  937 
of  pelvic  bones  in,  620 
of  sacrococcygeal  joint  in,  620 
of  skull  during,  933 
genito-urinary  fistula  in,  619 
heart -failure  in,  621 
hemorrhage  complicating,  572 
induction  of,  799 

in  placenta  prsevia,  577 
influence  of  fetal  pelvis  upon,  477 
of  justominor  pelvis  on,  474 
of  kyphotic  pelvis  on,  514 
of  obliquely  contracted  pelvis  on, 

481 
of  osteomalacic  pelvis  on,  498 
of  rachitic  pelvis  on,  492 
of  simple  flat  pelvis  on,  468 
of  spondylolisthetic  pelvis  on,  510 
injuries  of  anterior  vaginal  wall  in,  610 
of  urinary  tract  in,  619 
to  bowel  of  child  during,  938 
to  brain  during,  932 
to  cervix  uteri  in,  601 
to  face  during,  936 
to  infant  during,  932 
to  neck  of  fetus  during,  936 


i  Labor,  injuries  to  peripheral  nerves  dur- 
ing, 932 

to  scalp  during,  935 

to  trunk  of  child  during,  937 
inversion  of  uterus  in,  611.     See  also 

Uterus^  inversion  of. 
I      labia  in,  322 

lacerations  of  perineum  in,  333,  607 
causes,  334 
treatment,  334,  609 
I  of  vagina  in,  604 

of  vaginal  entrance  in,  607 

of  vestibule  in,  607 

of  vulva  in,  607 
leukocytes  after,  357 
liquor  amnii  in,  332 
management  of,  324 

in  kyphotic  pelvis,  516 

when  obstructed  by  contracted  pel- 
vis, 525     . 
manner  in  which  uterine  muscle  acts 

on  fetal  body  in,  393 
maturity  of  ovum  as  cause,  314 
mechanism  of,  388 

abnormalities  of,  402 

forces  involved  in,  392 

in  breech  presentation,  419 

in  brow  presentation,  416 

in  face  presentation,  409 

in  flat  pelvis,  468 

in  funnel-shaped  pelvis,  477 

in  justominor  pelvis,  474 

in  kyphotic  pelvis,  514 

in  obliquely  contracted  pelvis,  481 

in  occipito-anterior  position,  395 

in  occipitoposterior  position,  404 

in  osteomalacic  pelvis,  498 

in  rachitic  pelvis,  492 

in    right   occipito-anterior   position, 
404 

in  shoulder  presentation,  426 

in  third  stage,  433 

abnormalities  of,  434 

in  vertex  presentation,  395 
mental  impressions  in,  effect  of,  623 
missed,  188 
normal,  396 

accommodation  of  fetal  head  in,  396 

anterior  rotation  of  occiput  in,  398 

descent  of  head  in,  398 

dilatation  of  lower  uterine  cavity  and 
cervical  canal  in,  398 

external  rotation  in,  401 

propulsion  and  extension  of  head  in, 

399 

restitution  in,  399 

when    occiput    rotates    into    hollow 
of  sacrum,  407 
obstruction  of,  by  abnormal  conditions 
about  rectum,  553 

bv    abnormalities    in    fetal     mem- 
branes, 570 


INDEX. 


971 


Labor,    obstruction    of,    by    abscess   of 

Bartholin's  gland,  537 
by  anus  vaginalis  or  vestibularis,  535 
by  atresia  of  cervix  uteri,  530 

of  vagina,  535 
by  calculi  in  bladder,  553 
by  carcinoma  of  cervix  uteri,  545 
by  cicatrices  of  vagina,  534 
by  cicatricial  contraction  of  cervix 

uteri,  531 
by  closure  of  vagina,  533 
by  congenital  anomalies  of   uterus, 

53° 

narrowness  of  vagina,  538 
by  cystocele,  553 
by  death  of  fetus,  560 
by  diseases  of  fetus,  560 
by  displacement  of  cervix  uteri,  544 

of  uterus,  538 
by  double  uterus,  530 
by  edema  of  vulva,  537 
by  elephantiasis  of  vulva,  535 
by  enlarged  carunculae  myrtiformes, 

538 
by  former  fixation  of  uterus,  540 
by  gangrene  of  vulva,  537 
by  hematoma  of  vagina,  534 
by  hernia  of  pregnant  uterus,     539, 

540 
by  hydrencephalocele,  559 
by  hydrocephalus,  560 
by    hypertrophy    of    non-pregnant 

half  of  uterus  bicornis  or  didel- 

phys,  548 
by  large  fetal  head,  558 
by  lymphangioma  of  fetus,  559 
by  malformations  of  fetus,  558 
by  myxoma  of  fetus,  559 
by  ovarian  cysts,  549 

celiotomy  for,  551 
by  overgrowth  of  fetus,  554 
by  pendulous  belly,  539 
by  placenta  prsevia,  572.     See  also 

Placenta  prccvia. 
by  premature  ossification  of  cranium, 

558 
by  prolapse  of  uterus,  542 
by  rectocele,  553 
by  rigidity  of  cervix  uteri,  532 
by  sacculation  of  uterus,  542 
by  sacral  teratoma  of  fetus,  559 
by  septa  of  vagina,  533 
by  short  umbilical  cord,  570 
by  su])f)uration  of  vulva,  535 
by  tumors  of  fetus,  558 

of  genital  canal,  545 

of  vagina  and  vulva,  535 
by  twins,  565 

by  unruptured  hymen,  534 
by  uterine  displacements,  538 

fibroids,  545 

polypi,  548 


Labor,  obstruction  of,  by  vaginal  enter- 
ocele,  552 
hernia,  552 

by  vaginismus,  538 

by  varicose  veins,  538 

by  \\'ormian  bones,  558 
overdistention  (jf  uterus  as  cause,  314 
pains  of,  316 
pathology  of,  439 
periodicity  a  cause,  313 
preliminary  preparations  for,  324 
premature,  267 

care  of  child  after,  926 

induction  of,  799 

in  overgrowth  of  fetus,  554 
preparations  for,  324-327 
prevention    of    hemorrhage    in    third 

stage,  339 
profound  emotion  in,  623 
pulse  in,  357 

relaxation  of  pelvic  joints  after,  711 
resistant  forces  of,  excess  of,  445 
rupture  of  hematoma  in,  623 

of  respiratory  tract  in,  621 

of  sacro-iliac  joints  in,  619 

of  symphysis  pubis  in,  619 

of  uterus  in,  592.     See  also  Uterus, 
rupture  of. 
second  stage,  320 
shock  in,  621,  642 
signs  of,  315 

show,  316 
sloughs  of  scalp  from  injury  during, 

936 
stage  of  descent  in,  320 

of  dilatation  in,  320 

of  expulsion  in,  320 
stages  of,  320 

subcutaneous  emphysema  in,  621 
sudden  death  during  or  after,  621 
syncope  in,  623 
temperature  in,  324 
temporary  delirium  of,  257 
third  stage,  321,  341 
mechanism  of,  433 
abnormalities  in,  434 
thrombosis  of  pulmonary  artery  in,  623 
twin,  565 

coiling  of  cords  in,  567 

mechanism  of,  567 

l)la(enta  in,  568 

])resc'nta(ions  in,  565 

jjrognosis  of,  569 
uterine  contractions  in,   17 
vesicovaginal  lislula  in,  t)\q 
vulva  in,  321,  333 
Laceration   of  anterior   wall   of   vagina, 

treatment  of,  S74 
of  cervix  uteri,  repair  of,  898 
of  perineum  in  labor,  333,  607 
causes,  334 
treatment,  334,  609 


972 


INDEX. 


Laceration  of  posterior  wall  of  vagina, 
Emmet's  operation  for,  868- 
871 
treatment  of,  867 
of  sphincter  ani,  treatment  of,  867 
of  vagina  in  labor,  604 
of  vaginal  entrance  in  labor,  607 
of  vestibule  in  labor,  607 
of  vulva  in  labor,  607 

Lactalbumin  of  human  milk,  929 

Lactose,  929 

Langhan's  cells,  121 

Lanugo,  86 

Laparo-elytrotomy  in    labor    with    con- 
tracted pelvis,  530 

Larynx,  diseases  of,  in  pregnancy,  261 

Late  ligation  of  cord,  345 

Lateral  displacement  of  pregnant  uterus, 
220 

Lateroflexion  of  pregnant  uterus,  220 

Lateroposition  of  pregnant  uterus,  220 

Latero version  of  pregnant  uterus,  220 

Length  of  mature  fetus,  92 

Leukemia  in  pregnancy,  261 

Leukocytes  after  labor,  357 

Leukorrhea  in  pregnancy,  193 
vaginal,  in  pregnancy,  227 

Levator  ani,  importance  of,  26 

Levret's  forceps,  804 

Ligamentous  structures  of  pelvis,  27 

Ligatures,  preparation  of,  782 

Lilienthal's  portable  operating  table,  775, 
776 

Limbs  of  fetus,  fracture  of,  during  labor, 

937 
Linea  nigra,  199 

in  pregnancy,  199 
Linsol,  779 

Lipuria  in  pregnancy,  252 
Liquor  amnii,  100 

abnormalities  of,  108 
complicating  labor,  570 
of  secretion,  102 
composition  of,  loi 
deficiency  of,  102 
escape  of,  in  labor,  332 
excessive  quantity  of,  103 
in  labor,  332 
origin  of,  loi 
putrefaction  of,  108 
folliculi,  61 
Lithopedion,  174 

Liver,  degeneration  of,  in  pregnancy,  242 
diseases  of,  in  pregnancy,  242 
treatment,  243 
L.  O.  A.  presentation,  391 

explanation  of  frequency,  391 
Lochia,  353 
alba,  354 

in  puerperal  state,  353 
rubra,  354 
serosa,  354 


Lochial  tube,  Doderlein's,  730 

Nicholson's  modification,  731 
Locking  of  forceps,  817 
Lohlein's  method  of  measuring  transverse 

diameter  of  pelvic  inlet,  461,  462 
Longings  in  pregnancy,  187 
Loosening  of  finger  nails  in  pregnancy, 
266 

of  pelvic  joints  in  pregnancy,  236 
L.  O.  P.  presentation,  391 
Lordosis,  pelvis  of,  519 
Lowenhardt's     method     of     estimating 

duration  of  pregnancy,  211 
Lumbosacral  kyphosis,  512 
Lungs  in  pregnancy,  261 

in  puerperal  state,  359 

of  new-born  infant,  diseases  of,  941 
septic  infection  of,  873 
Lutein  in  corpus  luteum,  64 
Luxation  in  fetus,  166 

of  femora,  effect  of,  on  pelvis,  522 
Luys's    instrument    for    separation    of 

urines,  246 
Lymphangioma  of  fetus,  obstruction  of 

labor  by,  559 
Lymphatic  ducts  of  pelvic  organs,  32 
of  uterus  in  pregnancy,  181 


Mackenrodt's    operation    for    ureteral 

fistula,  890 
Mahler's  sign  in  puerperal  sepsis,  743 
Malaria  in  puerperal  state,  681 

of  fetus,  161 

relation  of,  to  puerperal  state,  772 
Male  pronucleus,  73 
Mammary  abscess,  709 
in  pregnancy,  236 

binder,  373' 

changes  in  puerperal  state,  360 

glands,  361.     See  Breasts. 

tumors,  711 

in  pregnancy,  236 
Manual  method  of  dilating  os  uteri,  786 

of  extracting  breech,  824 
Marginal  insertion  of  cord,  141 
Marriage,    average    date    of    conception 

after,  75  ^ 
Marshall     Hall's    method    of    artificial 

respiration,  940 
Martin's  pelvimeter,  449 
Masculine  pelvis,  472,  476 
Massage  of  breasts,  705 
Mastitis,  707 

of  new-born,  944 
Maternal  blood,  alterations  in,  as  cause 
of  abortion,  270 
fatal  to  fetus,  175 

emotions,  influence  of,  on  fetus,    i6g, 
624 

fever,  influence  of,  on  fetus,  168 
Maturation  of  ovum,  61 


INDEX. 


973 


Mature  fetus,  91 

dimensions  of  head  of,  92 
general  appearance,  92 
length  of,  92 
weight  of,  91 
Maturity  of  ovum  as  cause  of  labor,  314 
Mauriceau's  method  of  delivering  after- 
coming  head,  839 
Measles  in  fetus,  160 
in  pregnancy,  263 
in  puerperal  state,  679 
Mechanism    of    labor,     388.     See    also 
Labor,  mechanism  of. 
of  various  positions,  395 
presentations,  395 
Melancholia  in  pregnancy,  187 
Melena  of  new-born,  951 
Mellituria  in  pregnancy,  253 
Membrana  decidua  serotina,  147 
vera,  144 
granulosa  of  Graafian  follicle,  61 
reflexa,  144 
serotina,  144 
Membranes,     fetal,     abnormalities     of, 
complication  of  labor  by,  570 
retention    of,    puerperal    hemorrhage 
from,  649 
Menstrual  flow,  character  of,  60 
duration  of,  60 
quantity  of,  60 
molimina,  59 
Menstruation,  57 

and  ovulation,  connection  between,  65 
cessation  of,  60 

as  sign  of  pregnancy,  igi 
in  pregnancy,  191 
without  pregnancy,  192 
corpus  luteum,  65 
in  extra-uterine  pregnancy,  303 
recurrence  of,  during  pregnancy,  192 
time  of  onset,  59 
Mental  impressions  in  labor,  effect  of,  623 
Mesoderm,  78,  98 
Mesonej'hros,  42 
Metranoikter,  Schatz's,  789 
Metritis,  chronic,  as  cause  of  abortion, 

.^75. 

dissecting,  in  puerperal  sc])sis,  754 

in  pregnancy,  223 
treatment  of,  223 

septic    in  puery)cral  fever,  754 
Microbic  decidual  cnflomclritis,  153 
Miliary  tuberculosis  in  pregnancy,  262 
Milk,  anomalies  of  color,  704 

colostrum-corpuscles  in,  703 

cows',  constitution  of,  940 

effect  of  emotions  on,  699,  702 

fever,  360 

human,  as  food,  929 
constitution  of,  929 

qualitative  anomalies  in,  702 

f|uantily  of,  364 


Milk,  secretion  of,  695 
deficient,  696 

treatment  of,  699 
excessive,  700 
uterine,  121 
Milk-leg  in  puerperal  sepsis,  761 
Milk-tumor,  711 

Miscarriage,   257,   283.     See  also  Abor- 
tion. 
Missed  abortion,  283 

labor,  188 
Moles,  hydatidiform,  in 
tubal,  299 
vesicular,  114 
Molimina,  menstrual,  59 
Mons  veneris,  43 

Monsel's  solution   in   postpartum   hem- 
orrhage, 589 
Montgomery's  glands,  362 
inflammation  of,  704 
prominence  of,  in  pregnancy,  195 
Morning  sickness,  187 
in  pregnancy,  187 
Morphin  in  eclampsia,  638 

in  postpartum  hemorrhage,  591 
Morula,  78 

Mother,  chronic  diseases,  effect  on  fetus, 
176 
conditions  of,  which  injuriously  affect 

fetus,  168 
death  of,  effect  on  fetus,  170,  624 
directions  for,  374 
effect  of  death  of  fetus  on,  172 
spasmodic     muscular    action     in,     as 
cause  of  abortion,  269 
Mouth,  diseases  of,  in  pregnancy,  237 
Mouth-to-mouth  insufflation  in  asphyxia 

neonatorum,  940 
Mucous  plug,  184 
Mulberry  mass,  78 
Miillerian  ducts,  39,  40 
Miiller's   method  of  antepartum  fetom- 

etry,  465 
Multiple    births,    565.      Sec    also    Labor, 
twin. 
fetation,  95.   See  also  Fcl<ili(>i!,iiiii/tif>/r. 
prcgnanc\-,    95.      See    also    Fetation, 
multiple. 
Murjjhy's  breast  binder,  373 

continuous  instillation  of  salt  solution 
in  rectum  in  peritonitis,  759 
Muscle-flbers  of  uterus,   alterations,   in 

pregnancy,  180 
Aluscles,    abdominal,    diastasis    of,    in 
labor,  620 
])uerperal  state,  686 
of  pelvis,  26 

recti,  diastasis  of,  operative  trcalmcnt, 
920 
^^'ebster's  operation  for.  920 
Muscular     rheumatism      in      puer])eral 
state,  685 


974 


INDEX. 


Mycosis  of  vagina  in  pregnane}',  229 
Myelitis,  ascending,  in  puerperal  state, 

692 
Myocarditis  in  pregnane)',  259 
Myocardium,     brown     atrophy    of,     in 

pregnancy,  259 
Myoma,  cervical,  in  pregnancy,  225 

of  uterus,   vaginal   myomectomy  for, 
899 
Myomectomy,    vaginal,    for    myoma    of 

uterus,  technic,  899 
Myometrium,   rheumatism  of,   in   preg- 
nane}', 222 
Myxoma  fibrosum  placentae,  119 

of  chorion,  114 

relation,  to  syncytial  cancer,  116 

of  fetus,  obstruction  of  labor  by,  559 
Myxomatous  degeneration  of  placenta, 

127 
Myxosarcoma,  telangiectatic,  143 


Naboth's  glands  or  follicles,  47 
Naegele's  method  of  estimating  duration 
of  pregnancy,  210 
pelvis,  478 
Nasal  catarrh  of  new-born,  946 
Nausea  and  vomiting  in  pregnancy,  192 
Neck,  injuries  of,  during  labor,  936 
Necrosis  of  pelvis,  504 
Nephrectomy  for  ureteral  fistula,  889 
Nephritis,    differential    diagnosis,    from 
pregnancy,  248 
in  pregnancy,  247 

treatment,  249 
maternal,  effect  of,  on  fetus,  176 
Nerve  degeneration  in  puerperal  state, 

692 
Nerves  of  generative  organs,  32 
of  uterus  in  pregnancy,  181 
•vulvar,  exsection  of,  865 
Nerve-storms,  cardiac,  262 
Nervous   diseases   as  an  indication   for 
inducing  abortion,  798 
system,  alterations,  in  pregnancy,  194 
changes  in,  in  pregnancy,  187 
diseases  of,  in  pregnancy,  254 

in  puerperal  state,  692 
in  pregnancy,  187,  194 
Neumann-Ehrenfest  kliseometer,  463 

pelvigraph,  463,  464 
Neuralgia  in  pregnancy,  254 
Neurilemma,  181 
Neuritis  in  puerperal  state,  692 
Neuroses  of  pregnancy,  254 
New-liorn  infant,  923 
airing  of,  932 
aphthjc  of,  945 
artificial  feeding  of,  929 

respiration  of,  940 
asphyxia  of,  939 
atelectasis  of,  941 


New-born  infant,  atresia  ani  in,  945 

bathing  of,  931 

blood  in,  925 

bloody  discharge  from  female  gen- 
italia of,  953 

capacity  of  stomach  of,  924 

care  of,  344,  373 

directions  to  nurses  for,  376 

cephalhematoma  of,  935 

cleft-palate  of,  944 

clothing  of,  928 

colic  of,  946 

conjunctivitis  of,  948 

constipation  in,  946 

cyanosis  of,  949 

deformities  of,  treatment  of,  944 

digestion  in,  924 

diseases  of,  941 
of  lungs,  941 

exanthemata  of,  944 

eyesight  in,  925 

feeding  of,  928 

furuncles  in,  947 

gastro-intestinal      hemorrhage      in, 

952 
general  appearance  of,  92 
gonorrheal  stomatitis  of,  946 
harelip  of,  944 
heart  of,  926 

affections  of,  950 
hemidriosis  of,  949 
hemophilia  of,  949 
hemorrhage  from  umbilicus  in,  951 
icterus  of,  949 
inflammation    of    umbilical    vessels 

in,  951 
injuries  to,  during  labor,  932 
intussusception  in,  947 
jaundice  of,  849 
management  of,  928 
mastitis  of,  944 
medication  of,  953 
melena  of,  952 
mortality  of,  932 
movements  of  bowels  in,  924 
nasal  catarrh  of,  946 
nursing  of,  377 
omphalitis  in,  851 
ophthalmia  of,  948 
pathology  of,  932 
pemphigus  of,  947 

syphilitic,  948 
physiology  of,  923 
pneumonia  of,  942 
position  of  stomach  in,  924 
pulmonary  apoplexy  of,  943 
pulse  in,  925 
respiration  of,  923 

physiology  of,  939 
septic  infection  of  lungs  of,  942 

of  umbilicus  of,  950 
septicemia  of,  944 


IXBEX. 


97  S 


New-born  infant,  skin  diseases  of,  Q47 
sublingual  cysts  of,  946 
sudden  death,  953 
syphilis  of,  943 

of  lungs  of,  942 
temperature  of,  924 
tetanus  of,  952 
thrush  of,  946 
tuberculosis  of,  942 
umbilical  cord  in,  926 
fungus  in,  950 
hernia  in,  944 
urine  in,  924 
weight  of,  923 
wet-nurse  for,  929 
white  pneumonia  of,  942 
Nicholson's  modification  of  Doderlein's 
tube,  731 
telescopic  rod,  465 
Nipples,  anomalies  of,  695 
care  of,  189 

eczema  of,  in  pregnancy,  236 
in  pregnancy,  189 
sore,  706 
Nipple-shield,  707 
Nitrite  of  amyl  in  eclampsia,  639 
Nitroglycerin  in  eclampsia,  639 
Node  of  Hensen,  78 

diseases  of,  in  pregnancy,  261 
Nurse,  directions  for,  in  puerperal  state, 

376 
precautions  on  part  of,  in  puerperal 

sepsis,  736 
preparation  of,  for  abdominal  section. 

Nursing  in  puerperal  state,  377 

of  new-born  infant,  377 
Nymphac,  44 


Oblique  diameter  of  pelvic  inlet,  meas- 
urement of,  462 
of  pelvis,  22 
pelvis,    478.     See    also    Pelvis,    con- 
tracted, obliquely. 
Obstetric  examination  in  labor,  327 
operations,  773 

aseptic  technic  in,  773 
operative  technic  in,  773 
Obstetrical  binder,  341 

treatment  of  eclampsia,  639 
Obstetrics,  delinilion  of,  17 
Obturator  internus,  26 

membranes,  27 
Occi[)ito-anterior  position,  39 t 
mechanism  of  labor  in,  395 
right,  mechanism  of,  404 
Occipito-postcrior  position,  391 
diagnosis,  404 
forceps  in,  821 
mechanism  of  labor  in,  404 
prognosis,  408 


Occipito-posterior    position,    treatment, 

407 
Oligemia,  701 
Oligohydramnios,  102 
Omphalitis  of  new-born,  950 
Omjjhalorrhagia,  951 
One-child  sterility,  76 
05phorectomy,  technic  of,  gio 
Operating  mask,  Vienna,  780 
room,  furniture  of,  774 
hospital,  773 
private  house,  775 
suit,  780 
table,  777 
Hirst's,  775 

Lilienthal's  portable,  775,  776 
Ophthalmia  neonatorum,  948 
Os  uteri,  artificial  dilatation  of,  784.    See 

also  Cervical  canal,  dilatation  of. 
Osiander's  pelvimeter,  449 
Osseous  system,  diseases,  in  pregnancy. 

Ossification  of  cranium,  premature,  ob- 
struction of  labor  by,  558 
Osteomalacia  of  pregnancy,  263 
Osteomalacic  pelvis,  495 
Osteophytes  in  pregnaricy,  186 
Ostium  abdominale  of  oviduct,  53 

internum  of  oviduct,  53 
Outlet  of  pelvis,  18 
Ovarian  arteries,  32 

cysts  in  pregnancy,  225 

pregnancy,  285 

clinical  history,  292 
operation  for,  308 
terminations,  299 

veins,  ligation  or  exsection  of,  in  throm- 
bophlebitis, 743 
Ovario-abdominal  i)rcgnuncy,  285 
Ovariopclvic  ligament,  5O 
Ovarii)tomy  for  ovarian  cyst  comjjlicat- 

ing  ])regnancy,  549,  550 
Ovary,  anatomy,  53 

cysts  of,  complication  of  labor  by,  549 

development  of,  40 

germinal  cj)ithelium  of,  61 

interstitial  cells  of,  55 
Overdistention    of    uterus    as    cause    of 

labor,  314 
Oviducts,  anatomy,  -^t, 
Ovular  decidua,   147 
( )vulati()ii.  C)i 

and  menstruation,  connection  between, 

Ovule  and   spermatic   particle,   meeting 
place,  72 

migration  of,  external,  Si 
Ovum,  a])pcarance  of,  after  aliortion,  275 

changes  in,  following  impregnation,  78 

deutoplasm  of,  62 

discharge  of,  from  ovary,  62 

fertilization  of,  73 


9/6 


INDEX. 


Ovum,  germinal  spot,  62 

vesicle,  62 
implantation    of,    in    uterine  mucous 

membrane,  80 
internal  cell-membrane  of,  62 
karyokinesis  in,  62 
maturation  of,  61 

as  cause  of  labor,  314 
maturity  of,  as  cause  of  labor,  314 
migration  to  uterine  cavity,  62 
polar  globules  of,  62 
premature  expulsion  of,  26S,  269.     See 

also  Abortion. 
protoplasm  of,  64 
transmigration  of,  64 
vitelline  membrane,  62 
yolk,  62 

zona  pellucida,  62 
Oxygen  in  eclampsia,  639 


Pain  in  abortion,  272 

in  extra-uterine  pregnancy,  303 
in  pelvic  joints  in  pregnancy,  236 
Pains  of  labor,  316—318 
Palfyn's  forceps,  803 
Palpation,   abdominal,  at  end  of  puer- 
perium,  384 
diagnosis  of  position  of  fetus  by,  389 
in  labor,  388 
in  pregnancy,  200 
of  kidneys  at  end  of  puerperium,  385 
Panhysterectomy,  technic  of,  903 
Paralysis  in  puerperal  state,  692 

spinal,  in  pregnancy,  254 
Paraplegia  in  puerperal  state,  692 
Parathyroid  extract  in  eclampsia,  639 
Para-uterine  phlebitis  in  puerperal  sepsis, 

759 
Parovarium,  40,  42 
Parturition,  epistaxis  in,  261 
Patterson's  abdominal  supporter,  217 
Pelvic  bones,  fracture  of,  in  labor,  620 
cavity,  measurement  of  capacity  of,  462 
connective  tissue,  infection  of,  vaginal 

section  for,  752 
direction,  24 
engorgement,    puerperal    hemorrhage 

from,  658 
fascia,  28 

joints,  alterations  in,  in  pregnancy,  185 
ankylosis  of,  504 
changes  in,  in  pregnancy,  185 
loosening  of  and  pain  in,  in  preg- 
nancy, 236 
relaxation  of,  504 
after  labor,  711 
suppuration  of,  769 
synostosis  of,  504 
lymphatic  glands,  32 
organs,  blood-vessels  of,  32 
lymphatic  ducts  of,  32 


Pelvic  organs,  nerves  of,  32 

sensations  in,  in  pregnancy,  193 
peritonitis  in  puerperal  fever,  756 
position,  22 
shape,  20 
size,  22 

suppuration,  vaginal  section  for,  752 
tumors,  abdominal  section  for,  910 
pregnancy  and,  differentiation,  204 
putrefaction  of,  768 
Pelvigraph,  Neumann -Ehrenf est,  462 
Pelvimeter,  449 
Bylicki's,  460 
Farabeuf's,  459 
Harris-Dickinson,  449 
Hirst's,  457 
Martin's,  449 
Osiander's,  449 
Williams',  465 
Pelvimetry,  448 
.  Neumann-Ehrenfest,  463 
Skutsch's  method,  460,  461 
Pelvis,  achondroplastic,  473 
anatomy  of,  17 

obstetrically  considered,  20 
anomalies  of,   445.     See  also  Pelvis, 

deformities  of. 
assimilation,  484 
blood-vessels  of  organs  of,  32 
caries  of,  504 
cavitv  of,  measurement  of  capacity  of, 

462    _ 
connective  tissue  of,  28 
contracted.   Cesarean  section  in,  528, 

529 
forceps  in,  527 
generally,  4_75_ 

characteristics  of,  475 

diagnosis  of,  476 

etiology  of,  476 
induction    of    premature   labor    in, 

525 
management  of  labor  in,  525 
obliquely,  478 

characteristics  of,  478 

diagnosis  of,  480 

etiology  of,  479 

influence  of,  on  labor,  48 1 

prognosis  of,  481 

treatment  of,  482 
pubiotomy  in,  528 
transversely,  482 

cause  of,  483 

treatment  of,  483 
version  in,  527,  828 
coxalgic,  521 
cretin,  473 
deformities  of,  445 
classification,  446 
description,  466 
diagnosis,  448 
frequency,  445 


INDEX. 


977 


Pelvis,   deformities  of,  from  absence  of 
both  lower  extremities,  524 
of  one  lower  extremity,  524 

from  clubfoot,  525 

measurement  of  pelvic  outlet  in,  465 

Rontgen  rays  in,  448 
development  of,  24 
diameters  of,  22 
dwarf,  472,  473 

effect  of  luxation  of  femora  on,  522 
exostoses  of,  498 
fetal,  476 

diagnosis,  476 

influence  of,  upon  labor,  477 
flat  non-rachitic,  475 

rachitic,  486 

simple,  466 

characteristics  of,  466 
diagnosis  of,  468 
etiology  of,  467 
influence  of,  upon  labor,  468 
fractures  of,  501 
funnel-shaped,  476 

diagnosis,  476 

influence  upon  labor,  477 

measuring    posterior    sagittal  diam- 
eter in,  477 
hypoplastic,  473 
inclination  of,  22 
inferior  strait  of,  18 
inlet  of,  18 
justomajor,  483 
justominor,  472 

characteristics  of,  473 

diagnosis  of,  474 

etiology  of,  474 

influence  of,  on  labor,  474 
juvenile,  472 
kyphoscoliotic,  519 
kyphotic,  511 

characteristics  of,  512 

diagnosis  of,  517 

frequency  of,  518 

influence  of,  on  labor,  514 

management  of,  labor  in,  516 

prognosis  of,  518 
ligamentous  structures  of,  27 
lordosic,  519 

lymphatic  ducts  of  organs  of,  32 
masculine,  472,  476 
muscles  of,  26 
Naegele,  478 
nana,  472 
necrosis  of,  504 
nerves  of  organs  of,  32 
obtecta,  514 

of  kidney,  diseases,  in  jjregnancy,  250 
ostetjmalacic,  495 

diagnosis  of,  497 

influence  of,  upon  labor,  498 

treatment  of,  498 
outlet  of,  18 

62 


Pelvis  plana,  466 
position  of,  22 

pseudo-osteomalacic,  4S6,  489 
rachitic,  484 

characteristics  of,  485 

diagnosis  of,  490 

flat,  486 

influence  of,  on  labor,  492 
Robert,  482 
scoliotic,  518 
shape  of,  20 
simple  flat,  466 
sitz-,  524 
size  of,  22 
soft  tissues  of,  25 
spinosa,  498 
split,  484 
spondylolisthetic,  505 

characteristics  of,  505 

diagnosis  of,  507 

etiology  of,  507 

frequency  of,  507 

influence  of,  upon  labor,  510 

treatment  of,  511 
superior  strait  of,  18 
true,  17 
tumors  of,  498 

pregnancy  and,  differentiation,  204 
undeveloped,  476 
Pemphigus  of  new-born,  947 

syphilitic,  948 
Pendulous  belly,  obstruction  of  labor  by, 

539 
Peptonuria  from  death  of  fetus,  173 

in  pregnancy,  253 
Perforator,  Blot's,  843,  844 

Smellie's,  844,  845 
Perineovaginal  fistula,  treatment  of,  864 
Perineum,  lacerations  of ,  Emmet's  opera- 
tion for,  868-871 
in  labor,  333,  607 
causes,  334 
treatment,  334,  609 
supporting,  335 
Periodicity  as  cause  of  lal)or,  313 
Peripheral  nerves,   diseases  of,   in  i)rcg- 
nancy,  254 
in  ])regnanc\',  254 
injurv  to,  during  labor,  932 
Peritoneal   covering  of  uterus,  changes, 

in  ])regnancy,  180 
Peritonitis,   ditTusc,    in   pucri)cral   sepsis, 

suppurative,  abdominal  section   for, 

I'owler's  position  alter  operation 

for,  758 
Murphy's  treatment,  759 
lymphatica  in  puerperal  sepsis,  757 
pelvic,  in  j)ucr])eral  fever,  756 
Peri-uterine  adhesions  in  ])regnancy,  235 
inflammations  in  pregnancy,  235 


978 


INDEX. 


Pernicious  anemia  in  pregnancy,  261 
vomiting  in  pregnancy,  237.     See  also 
Vomiting. 
Ferret's  method  of  antepartum  fetometrv, 

466 
Pessary,  insertion  of,  method,  912 
Piiiiger's  theory  of  menstruation,  57 
Phlebitis,  para-uterine,  in  puerperal  sep- 
sis, 759 
uterine,  in  puerperal  sepsis,  759 
Phlegmasia    alba    dolens    in    puerperal 

sepsis,  761 
Phthisical  placenta,  127 
Phthisis  in  puerperal  state,  672 
pulmonalis  in  pregnancy,  262 
Pigmentation,  exaggerated,  in  pregnancy, 
266 
of  areolcc,  exaggerated,  706 
Pilocarpin  in  eclampsia,  639 
Placenta,  120 
abscess  of,  130 
adhesions  of,  435 
causes,  436 
diagnosis,  436 
treatment,  436 
anatomy  of,  122 
annular,  127 
anomalies  of,  125 
of  number,  126 
of  position,  125 
of  shape,  126 
of  size,  125 
of  weight,  125 
battledore,  141 
calcareous  degeneration,  127 
circular  sinus  of,  rupture  of,  585 

vein  of,  124 
cotyledons  of,  124 
cysts  of,  131 
delivery  of,  341 

in  twin  labor,  568 
detachment  of,  344 
premature,  583 
causes,  583 
diagnosis,  584 
frequency,  583 
prognosis,  585 

rupture  of  circular  sinus  and,  5S5 
symptoms,  584 
treatment,  585 
development  of,  120 
duplex,  126 
edema  of,  127 

expression  of,  Crede's  method,  343,  434 
expulsion  of,  mechanism  of,  433 
functions  of,  125 
hemorrhage  of,  130 
hernia  of,  438 
in  multiple  fetation,  96 
manner  of  separation  of,  323 
membranacea,  iii,  126 
multiloba,  126 


Placenta,  myxomatous  degeneration  of, 

I27_ 

phthisical,  127 
praevia,  572 

abortion  in,  577 
Cesarean  section  for,  581 
clinical  history,  575 
diagnosis,  577 
etiology,  573 
frequency,  572 
hemorrhage  in,  575 
history,  572 

induction  of  labor  in,  577 
prognosis,  582  ■ 

symptoms,  577 
tampon  in,  581 
treatment,  577 
varieties,  574 
Wigand's  treatment,  581 
prolapse  of,  438 
retention  of,  434,  571 

Crede's  method  of  expressing,  435 
in  double  uterus,  531 
prognosis,  438 

puerperal  hemorrhage  from,  649 
spirochseta  pallida  in,  129 
spurise,  126 
succenturiatffi,  126 
syphilis  of,  128  ; 

tripartita,  126 
tuberculosis  of,  130 
tumors  of,  131 
symptoms,  135 
treatment,  136 
villi  of,  120 

degeneration  of,  127 
Placentae  spuriae,  126 
succenturiatas,  126 
Placental  decidua,  147 
hemorrhages,  130 
infarcts,  127 
polypi,  malignant,  132 
syphilis,  128 

villi,  degeneration  of,  127 
Plane  of  pelvic  contraction,  21 

expansion,  21 
Plastic  operation,   preparation  for,   782, 
-864 
evening  before,  782 
morning  of  operation,  782 
Plethora,  maternal,  effect  of,  on  fetus,  175 
Pleurisy  in  pregnancy,  262 

in  puerperal  state,  674 
Plexuses,  sacral,  lesions  of,  in  puerperal 

state,  692 
Pneumococcus  in  puerperal  sepsis,  724 
Pneumonia  in  pregnancy,  261 
in  puerperal  state,  672 
labor  complicated  by,  642 
of  fetus,  163 
of  new-born  infant,  942 
Podalic  version,  830 


INDEX. 


979 


Poisoning,  chronic,  of  mother,  influence, 

on  fetus,  176 
Polar  globules,  62 
Polygalactia,  700 
Polyhydramnion,  103 
Polymastia,  693 
Polypi,  cervical,  in  pregnancy,  225 

placental,  malignant,  132 

uterine,  obstruction  of  labor  by,  548 
Polypoid  endometritis,  149 

hypertrophies  of  vaginal  mucous  mem- 
brane in  pregnancy,  229 
Polyuria  in  pregnancy,  252 
Pomeroy's  bag  for  artificial  dilatation  of 

cervical  canal,  784 
Porro's  method  of  Cesarean  section,  857 
Position,  definition  of,  388 

mechanism  of,  395 

occipito-anterior,  391 

mechanism  of  labor  in,  395 
right,  mechanism  of,  404 

occipito-posterior,  391.     See  also  Oc- 
cipito-posterior  position. 

of  fetus,   diagnosis  of,  by  abdominal 
palpation,  389 
by  auscultation,  390 
Postmammary  abscess,  711 
Postmortem  Cesarean  section,  856 

delivery,  624 
Postpartum  hemorrhage,  585.     See  also 

Hemorrhage,  postpartum. 
Postural  version,  829 
Posture,  Walcher,  528,  529 
Pott's  disease  in  pregnancy,  263 
Poulet's  forceps,  808 
Prague's    method    of    delivering    after- 
coming  head,  840 
Pregnancy,  17 

abdomen  in,  195 

abdominal,  285.     See  also  Abdominal 
pregnancy. 

accidents  of,  266 

acetonuria  in,  253 

albuminuria  in,  253 

albuminuric  retinitis  in,  249 

aneurysm  in,  260 

anomalies  of  urine  in,  252 

anteflexion  of  uterus  in,  215 

appendicitis  in,  243 

areola  in,  194 

asthma  in,  262 

auscultatory  sounds  of,  203 

auto-intoxication  in,  263 

ballottement  in,  203 

blindness  in,  256 

blood  in,  185,  261 

Braun-Fcrnwald's  sign,  202 

breasts  in,  194,  236 

broad  ligament  in,  287 

bronchial  catarrh  in,  261 

brown  atrophy  of  myocardium,  259 

cancer  of  cervix  in,  225 


Pregnancy,  cancer  of  uterus  in,  225 

of  vagina  in,  231 

of  vulva  in,  233 
cardiac  nerve-storms  in,  186 
caries  of  teeth  in,  237 
catheterization  of  ureters  in,  244 
cervical  myoma  in,  225 

of  Roktansky,  154 

polyps  in,  225 
cervicitis  in,  225 
cervix  uteri  in,  199,   201 
cessation  of  menstruation  in,  191 
changes  in  abdomen,  193 

"n  abdominal  walls,  185 

in  bladder,  185 

^n  blood,  193 

^n  breasts,  193 

n  cervix,  184 

in  circulatory  system,  185 

in  digestive  tract,  187 

in  heart,  186 

in  nervous  system,  187,  194 

in  pelvic  joints,  185 

in  rectum,  1S5 

in  respiratory  apparatus,  187 

in  several  bodily  systems,  185 

n  size  and  shapje  of  abdomen,  193 

,n  thyroid  gland,  187 

in  urine,  186 

in  uterus,  180 

in  vagina,  185 

in  vulva,  185 

in  weight,  187 
changes  in,  due   to  increased   blood- 
supply  to  genitalia  and  breasts,  193 
chloasma  in,  194,  266 
chorea  in,  254 

treatment,  255 
chyluria  in,  253 
colostrum  in,  195 
colpitis  emphysematosa  in,  229 
colpohyperplasia  cystica  in,  228 
combined  visual  and  touch  examina- 
tion, 201 
congestion  of  brain  in,  254 
constipation  in,  188 

treatment,  242 
corpus  luteum,  65 
cystitis  in,  252 
cystoscopy  of  ureters  in,  244 
degeneration  of  liver  in,  243 
delirium  of  fever  in,  257 
fliabetcs  mellilus  in,  253 
diagnosis  of,  189-215 

by  sense  of  touch,  200 

diflerential,  from  tumors,  204 

mistakes  in,  189 
diarrhea  in,  treatment,  242 
diet  in,  1S9 

diminution  f)f  urine  in,  252 
diseases  of  alimentary  canal  in,  237 

of  I)ladder  in,  251 


980 


INDEX. 


Pregnancy,  diseases  of  blood  in,  261 

of  blood-vessels  in,  259 

of  brain  in,  254 

of  bronchi  in,  261 

of  cervix  in,  225 

of  circulatory  apparatus  in,  257 

of  eyes  in,  256 

of  heart  in,  257 
prognosis,  258 
treatment,  258 

of  heart-muscle  in,  259 

of  intestines  in,  242 

of  larynx  in,  261 

of  liver  in,  242 
treatment,  243 

of  mouth  in,  237 

of  nervous  system  in,  254 

of  nose  in,  261 

of  osseous  system  in,  263 

of  pelvis  of  kidney  in,  250 

of  peripheral  nerves  in,  254 

of  respiratory  apparatus  in,  261 

of  skin  in,  264 

of  spinal  cord  in,  254 

of  stomach  in,  237 

of  urinary  apparatus  in,  244 

of  uterine  muscle  in,  222 

of  vagina  in,  227 

of  vulva  in,  231 
dislocation  of  kidney  in,  250 
displacements  of  uterus  in,  215 
disturbances  of  hearing  in,  256 

of  vision  in,  256 
dulness  on  percussion  in,  203 
duration,  estimation  of,  210 
early,  Hegar's  sign,  201 
ectopic,    284.     See  also  Extra-uterine 

pregnancy. 
eczema  of  nipples  in,  236 
edema  of  cervix  uteri  in,  225 

of  glottis  in,  261 

of  vulva  in,  234 
emphysema  in,  261 
endocervicitis  in,  225 
enlargement  of  uterus  in,  202 
epilepsy  in,  255 
epistaxis  in,  261 

exaggerated  pigmentation  in,  266 
examination  of  urinary  tract  and  urine 
in,  244 

of  urine  in,  188,  244 
exercise  in,  188 

exposure  to  cold,  wet,  or  draft  in,  189 
extra-uterine,    284.     See    also    Extra- 
uterine pregnancy. 
eyes  in,  256 
face  of  woman  in,  194 
fetal  heart-sounds  in,  203 
movements  in,  193,  204 
auscultation,  204 
palpation,  201 
fibroma  of  uterus  in,  223 


Pregnancy,   fibromyoma  of   round  liga- 
ment in  groin  in,  225 
of  uterine  muscle  in,  223 

first  trimester,  signs  in,  204 

funic  soufifle  in,  204 

general  changes  in,  185 

gingivitis  in,  237 

goiter  in,  259 

gonococcus  infection  in,  227 

Goodell's  sign  of,  201 

Graves'  disease  in,  259 

hearing  in,  256 

heart  disease  in,  257 

Hegar's  sign,  201. 

hematuria  in,  253 

hemoptysis  in,  262 

hemorrhoids  in,  244 

hernial  protrusion  of  uterus  in,  222 

herpes  in,  265 

hydronephrosis  in,  251 

hypertrichosis  in,  199 
■  hysteria  in,  255 

impetigo  herpetiformis  in,  264 

in  horn  of  uterus  bicornis  or  unicornis, 

.309 

in  uterus  bicornis,  309     . 
unicornis,  309 

incarceration  of  uterus  in,  216 

incontinence  of  urine  in,  252 

indigestion  in,  242 

infectious  diseases  in,  263 

inflammatory  diseases  of  brain  in,  254 
of  spinal  cord  in,  254 

influenza  in,  263 

injuries  of,  266 

insanity  in,  256.     See  also  Insanity. 

interstitial,   285.     See  also  Interstitial 
pregnancy. 

intestines  in,  242 

irritability  of  bladder  in,  251 
treatment,  252 

jaundice  in,  242 

Johnson's  sign  of,  199,  201 
Jorisenne's  sign  of,  186 

kidney  of,    246.     See  also  Kidney  of 

pregnancy. 
lateral  displacements  of  uterus  in,  220 
lateroflexions  of  uterus  in,  220 
lateroposition  of  uterus  in,  220 
lateroversion  of  uterus  in,  220 
leukemia  in,  261 
leukorrhea  in,  193 
linea  nigra  in,  199 
lipuria  in,  252 
longings  in,  187 
loosening  of  finger  nails  in,  266 

of  pelvic  joints  in,  236 
mammary  abscess  in,  236 

tumors  in,  236 
management  of,  188 
measles  in,  263 
melancholia  in,  1S7 


INDEX. 


981 


Pregnancy,  mellituria  in,  253 

metritis  in,  223 

miliary  tuberculosis  in,  262 

morning  sickness  in,  187 

multiple,  95.     See  also  Fetation,  multi- 
ple. 

mycosis  of  vagina  in,  229 

myocarditis  in,  259 

nausea  and  vomiting  in,  192 

nephritis  in,  247 
treatment,  249 

nervous  system  in,  187 

neuralgia  in,  254 

neuroses  of,  254 

new  growths  of  uterine  muscle  in,  223 

nipples  in,  1S9 

objective  signs,  194 

obscurity  of  vision  in,  249 

osteomalacia  of,  263 

osteophytes  in,  186 

ovarian,  285.     See  also  Ovarian  preg- 
nancy. 

ovario-abdominal,  285 

palpation  of  abdomen  in,  200 

pathogenic  micro-organisms  in  vagina 
in,  227 

peptonuria  in,  253 

peri-uterine  adhesions  in,  235 
inflammations  in,  235 

pernicious  anemia  in,  261 

vomiting  in,  237.     See  also  Vomit- 

i'[g- 
phthisis  pulmonalis  in,  262 
physiology  of,  180 
pleurisy  in,  262 
pneumonia  in,  261 
pointed  condyloma  of  vulva  in,  231 
polypoid     hypertrophies     of     vaginal 

mucous  membrane  in,  229 
polyuria  in,  252 
Pott's  disease  in,  263 
prior,  diagnosis  of,  213 
prolapse  of  uterus  in,  220 
prolongation  of,  188 
pruritus  in,  265 

vulviL-  in,  233,  265 
psychical  disturbances  in,  256 
ptyalism  in,  193,  237 
jjulmonary  embolism  in,  262 

tuberculosis  in,  262 
purpura  haitnorrhagica  in,  261 
pyelitis  in,  250 

treatment,  251 
quickening  in,   193 
renal  calculus  in,  251 

tum(jrs  in,  250 
respiratory  api)aratus  in,  187,  261 
retroflexion  of  uterus  in,  216.     See  also 

Retroflexion. 
retroversion  of  uterus  in,  216 
rheumatism  of  myometrium  in,  222 
rupture  of  uterus  in,  266 


Pregnancy,  salivation  in,  192 
sarcoma  of  vagina  in,  231 

of  vulva  in,  233 
second  trimester,  signs  in,  204 
secondary,  301 
sensations  in  breasts  in,  193 
signs  of,  191 

divisions  of,  204 

objective,  194 

on  auscultation,  203 

on  inspection,  194 

on  sense  of  touch,  200 

subjective,  191 
skin  diseases  in,  264 
spinal  paralyses  in,  254 
spurious,  214 
stria;  in,  mammary,  194 
subjective  signs,  191 
suburethral  abscess  in,  229 
surgical  operations  in,  267 
swelling  of  old  varices  as  indication, 

syphilis  in,  264 

teeth  in,  189 

tetany  in,  255 

third  trimester,  signs  in,  204 

toothache  in,  237 

torsion  of  uterus  in,  222 

toxemia  in,  263 

tubal,  285.     See  clIso  Tubal  pregnancy. 

tubo-abdominal,  301 

tubo-ovarian,    285.     See    also    Tiibo- 

ovarian  pregnancy. 
tubo-uterine,  285 
typhoid  fever  in,  263 
umbilicus  in,  199 
urinalysis  in,  188,  245 
urine  in,  188,  244 
uterine  bruit  in,  204 
utero-abdominal,  285.     See  also  Utero- 

abdotninal  pregnancy. 
uterus  in,  180 
vagina  in,  199 
vaginal  cysts  in,  231 

leukorrhea  in,  227 
varices  of  labia  majora  in,  231 

of  vagina  in,  229 
varicose  veins  in,  21^9 

rupture,  266 
vegetations  of  vulva  in,  231 
venereal  warts  of  vulva  in,  231 
vesical  calculi  in,  252 

hemorrhoids  in,  252 
vomiting  in,  192 

pernicious,  237.     See  also  Vomiting. 
vulva  in,  199 
weight  in,   1S7 
Pregnant  uterus,  abortion  of,  218 

alterations  in,  180 

anteflexion  of,  215 
treatment,  216 

displacements  of,  215 


982 


INDEX. 


Pregnant  uterus,  expulsion  of,  218 

forming  part  of  hernial  protrusion, 

222 
hernia  of,  obstruction  of  labor  by,  539 

540 
incarceration  of,  216,  218 

treatment,  219 
lateral  displacements  of,  220 
lateroflexion  of,  220 
lateroposition  of,  220 
latero version  of,  220 
prolapse  of,  220 

spontaneous  terminations,  221 

treatment,  222 
relation  of,  to  intestines,  183 
retroflexion  or  retroversion  of,  216. 

See  also  Retroflexion. 
sacculation  of,  218 
spontaneous  reposition  of,  218 
torsion  of,  222 
Premature     infants,     abnormalities     in 

physiology  of,  926 
gavage  of,  927 
management  of,  926 
sclerema  of,  929 
labor,  267 

in  contracted  pelvis,  525 
in  overgrowth  of  fetus,  554 
induction  of,  799 
ossification  of  cranium,  obstruction  of 
labor  by,  558 
Presentation,  breech,  419 
blunt  hook  in,  827 
causes  of,  419 
diagnosis  of,  419 
extraction  of,  824 

by  fillet,  826 

by  manual  method,  824 
forceps  in,  826 
frequency  of,  419 
mechanism  of,  419 

abnormalities  in,  425 
prognosis  of,  424 
treatment  of,  425 
brow,  416 

diagnosis  of,  416 
frequency  of,  416 
mechanism  of,  416 
prognosis  of,  416 
treatment  of,  416 
cephalic,  explanation  of  frequency,  390 
compound,  563 

treatment  of,  564 
definition  of,  388 
diagnosis  of,  by  abdominal  palpation, 

389 
by  auscultation,  390 
by  vaginal  examination,  391 
face,  409 

cause  of,  410 
diagnosis  of,  409 
frequency  of,  409 


Presentation,  face,  mechanism  of,  410 
abnormalities  in,  412 
prognosis  of,  414 
treatment  of,  414 
L.  O.  A.,  explanation  of  frequency,  391 
mechanism  of,  395 
abnormalities  in,  402 
management,  402 
of  greater  fontanel,  417 

treatment,  418 
R.  O.  P.,  explanation  of  frequency,  391 
shoulder,  426 
causes  of,  431 
diagnosis  of,  426 
mechanism  of,  431 
treatment  of,  433 
version  in,  433 
transverse,  426 
varieties,  395 
vertex,  395 
diagnosis,  395 

explanation  of  frequency,  39 1 
mechanism  of  labor  in,  395 
positions  of,  391 
Priapism   from    injury   to   brain    during 

labor,  932 
Primitive  groove,  78 

streak,  78 
Private  house  operating  room,  775 

preparation  for  abdominal  section  in, 

.899 
Proctitis,  septic,  in  puerperal  sepsis,  768 
Prolapse  of  placenta,  438 
of  pregnant  uterus,  220 

spontaneous  terminations,  221 
treatment,  222 
of  umbilical  cord,  625 
Prolapse  of  uterus,  complication  of  labor 

by,  542  ' 
obstruction  of  labor  by,  542 
Promontory,  double,  468 
Pronucleus,  female,  73 

male,  73 
Prosopothoracopagus,  543 
Protargol  in  puerperal  sepsis,  740 
Proteids  of  milk,  929 
Protoplasm  of  ovum,  62 
Pruritus  in  pregnancy,  265 

of  vulva,    exsection   of   vulvar   nerves 
for,  865 
in  pregnancy,  233,  265 
Pseudocyesis,  214 

Pseudo-osteomalacic  pelvis,  486,  489 
Psvchical    disturbances    in     pregnancy, 

256 
Ptyalism  in  pregnancy,   193,  237 
Pubes,  fracture  of,  502 
Pubiotomy,  854 

in  labor  with  contracted  pelvis,  528 
Puerperal  anemia,  648 

fever.      See  Puerperal  sepsis. 

gangrene,  763 


INDEX. 


983 


Puerperal    hematoma,    659.      See    also 

Hematoma,  puerperal. 
hemorrhage,    649.     See    also   Hemor- 
rhage, puerperal. 
infection.     See  Puerperal  sepsis. 
insanity,  256 
sepsis,  712 

abdominal  section  in,  741 
exploratory,  751 

argyrol  in,  740 

atmosphere  in,  732 

bacteria  of,   manner  in  which  they 
find  entrance,  725 
that  produce,  723 

bacterin  treatment,  739 

bacteriologic  examination  of  uterine 
cavity  in,  731 

bacteriology,  715-726 
of  blood  in,  732 

behavior  of  bacteria  in  genital  canal, 
726 

blood-cultures  in  diagnosis  of,  731 

care  of  patient  in,  734 

cellulitis  in,  754 

clinical  history,  752 

collargol  in,  740 

colloidal  silver  in,  740 

Crede's  ointment  in,  740 

curative  treatment,  737 

diagnosis,  728,  752 

diffuse  peritonitis  in,  756 

dissecting  metritis  in,  754 

endocol])itis  in,  753 

endometritis  in,  753 

etiology,  715 

explorating    abdominal    section    in, 

historical  review,  712 
hypodermoclysis  in,  740 
hysterectomy  for,  746 
ischiorectal  abscess  in,  769 
Mahler's  sign  in,  743 
meritis  in,  754 
milk-leg  in,  761 
morl)id  anatomv,  7^2 
o[)erative  treatment  of,  740 
para-uterine  f)hlebitis  in,  759 
pelvic  peritonitis  in,  70 
peritonitis  lymphatica  in,  757 
phlegmasia  alba  dolens  in,  761 
precautions  in  regard  to  implements, 

736 
on  part  of  nurse  in,  736 

of  physician  in,  735 
preventive  treatment,  732 

of  physician  in,  735 
proctitis  in,  76S 
protargol  in,  740 

putrefaction  of  pelvic  and  abdomi- 
nal tumors  in,  768 
putrid  absorjjlion  in,  764 
pyelitis  in,  766 


Puerperal  sepsis,  relation  of  diphtheria 
to,  771 

of  erysipelas  to,  771 

of  infectious  fevers  to,  769 

of  malaria  to,  772 

of  scarlet  fever  to,  771 
saline  solutions  in,  740 
salpingitis  in,  753 
salpingo-oophorectomy  for,  745 
sapremia  in,  764 
septic  cystitis  in,  766 

metritis  in,  754 

proctitis  in,  768 
septicemia  in,  764 
serum-therapy,  739 
suppuration  of  pelvic  joints  in,  769 
symptoms,  728 
tetanus  in,  768 
thrombophlebitis  in,  743 
treatment,  737 

by  artificial  hyperleukocytosis,  739 

by  washing  blood,  740 

curative,  737 

preventive,  732 
trimethylamin  in  vaginal  secretions 

in,  722 
thrombophlebitis  in,  743 
ureteritis  in,  766 
uterine  phlebitis  in,  759 
water  in,  733 
state,  347 

abdominal  palpation  at  end  of,  384 
acute  intercurrent  affections  in,  672 
after-pains  in,  356 
alterations  in  circulatory  apparatus 

in,  .357 
anemia  in,  648 
aphasia  in,  692 
apoplexies  in,  692 
appetite  in,  359 
arthritis  in,  6S3 
ascending  myelitis  in,  692 
bowels  in,  371 
breasts  in,  care  of,  371 
care  of  child  during,  373 
catheterization  in,  370 
change  in  urinarv  system  in,  358 
diagnosis,  364 
fliastasis  of  abdominal   muscles  in, 

6S6 
diet  in,  36S 
digital  examination  of  vagina  at  end 

of,  3S0 
dijihthcria  in,  fiSi 
directions  for  mother,  374 

to  nurse  for,  376 
diseases  of  nervous  system  in,  692 

of  urinary  system  in,  687 
dislocation  of  kidnev  in,  6or 
distention  of  a])domen  in,  686 
edema  of  genitals  in,  64() 
erysipelas  in,  697 


984 


INDEX. 


Puerperal  state,  erythematous  rashes  in, 

67S 
examination  of  coccyx  at  end  of,  385 
exanthemata  in,  674 
fever  in,  emotional,  665 

from  cerebral  disease,  670 

from  constipation,  668 

from  exposure  to  cold,  668 

from  reflex  irritation,  668 

from  sun-stroke,  671 

non-infectious,  665 

persistence  or  exacerbation  of,  672 

syphilitic,  671 

with  eclampsia,  670 
fibroids  in,  658 

final  examination  at  end  of,  377 
glycosuria  in,  359 
gonorrhea  in,  685 

hematoma  in,  659.     See  also  Hema- 
toma. 
hematuria  in,  690 
hemiplegia  in,  692 
incontinence  of  urine  in,  691 
insolation  in,  671 
inspection  of  vulva  at  end  of,  377 
involution  of  uterus  in,    348.     See 

also  Involution  0}  uterus. 
kidneys  in,  690 

lesions  of  sacral  plexuses  in,  692 
lochia  in,  353 
lungs  in,  359 
malaria  in,  681 
mammary  abscess  in,  709 

glands  in,  care  of,  371 
changes  in,  360 
management,  364 

visits  during,  365 
mastitis  in,  707 
measles  in,  679 
milk  fever  in,  360 
nerve  degeneration  in,  692 
nervous  system  in,  692 
neuritis  in,  692 
nursing  in,  377 

palpation  of  kidneys  at  end  of,  385 
paralysis  in,  692 
paraplegia  in,  692 
pathologv,  644 
phthisis  in,  672 
physician's  visits  during,  365 
pleurisy  in,  674 
pneumonia  in,  672 
position  of  uterus  at  end  of,  382 
pulse  in,  357 

relation  of  malaria  to,  772 
rest  and  quiet  in,  365 
rheumatism  in,  683 

muscular,  685 
rotheln  in,  679 
scarlet    fever    in,     674.     See     also 

Scarlet  fever  in  puerperal  stale. 
secretion  of  milk  in,  695 


Puerperal  state,  skin  diseases  in,  686 
small-pox  in,  679 
specular  examination  of  vagina  and 

cervix  at  end  of,  382 
sun-stroke  in,  671 
sweat-glands  in,  359 
temperature  in,  360 
thirst  in,  359 
tympanites  in,  686 
urinary  system  in,  687 
urination  in,  369 
urine  in,  687 
visits  of  friends  in,  367 
weight  in,  changes  in,  360 
Puerperium,    347.     See    also    Puerperal 

state. 
Pulmonary  apoplexy  of  new-born,  943 
embolism  in  labor,  623 

in  pregnancy,  262 
thrombosis  in  labor,  623 
Pulse  during  labor,  357 
in  new-born  infant,  925 
in  puerperal  state,  357 
Puncture  of  labia  for  edema  of  vulva,  234 

of  membranes  in  eclampsia,  639 
Purpura  hsemorrhagica  in  pregnancy,  261 
Purulent  decidual  endometritis,  153 
Putrefaction  of  liquor  amnii,  108 

of  pelvic  and  abdominal  tumors,  768 
Putrid  absorption    in  puerperal    sepsis, 

764 
Pyelitis  in  pregnancy,  250 
treatment,  251 
in  puerperal  sepsis,  766 
Pygopagus,  birth  of,  558 
Pyriformis  muscle,  26 


Quickening,  86,  193 

value    of,    in    estimating    duration    of 
pregnancy,  211 


Rachitic  pelvis,  484.     See  also  Pelvis, 

rachitic. 
Rachitis  of  fetus,  163 
Ramsbotham's  hook,  849 
Recti    muscles,    diastasis    of,    operative 
treatment,  920 
Webster's  operation  for,  920 
Rectocele,  obstruction  of  labor  by,  553 
Rectovaginal  septum,  tear  of,  treatment, 

874 
Rectum,     abnormal     conditions    about, 
obstruction  of  labor  by,  553 
changes  in,  in  pregnancy,  185 
imperforate,  of  child,  treatment  of,  945 
Recurrent  fever  of  fetus,  162 
Relaxation  of  pelvic  joints,  504 

after  labor,  711 
Renal  calculus  in  pregnancy,  251 
tumors  in  pregnancy.  250 


INDEX. 


985 


Resistance,  forces  of,  392 

of  labor,  excess  in,  445 
Resisting  hymen,  treatment  of,  864 
Respiration  of  new-born  infant,  923 

physiology  of,  939 
Respiratory    apparatus,    changes   in,    in 
pregnancy,  187 
diseases  of,  in  pregnancy,  261 
tract,  rupture  of,  in  labor,  621 
Restitution,  anomalies  of,  403 
in  face  presentation,  412 
in  vertex  presentation,  399 
Retention  of  placenta,  434,  571 

Crede's  method  of  expressing,  435 
prognosis,  438 
of  urine  in  puerperal  state,  369 
Retrodisplacement  of  uterus,  treatment, 
911.     See    also    Uterus,    retrodisplace- 
ment of. 
Retroflexion  of  pregnant  uterus,  216 
prognosis,  218 
symptoms,  216 
terminations,  218 
treatment,  218 

when  uterus  is  incarcerated,  219 
Retroplacental  effusion,  323 
Retro-uterine  hematocele,  302 
Retroversion  of  pregnant  uterus,  216 
Rheumatism,  articular,  of  fetus,  162 
in  puerperal  state,  683 
muscular,  in  puerperal  state,  685 
of  mvometrium  in  pregnancy,  222 
Ring  of  Bandl,  182,  392,  593 
R.  O.  A.  presentation,  391 
Robert  pelvis,  482 
Rochester  sterilizer,  774 
Rontgen  rays  in  diagnosis  of  pelvic  de- 
formities, 448 
R.  O.  P.  presentation,  391 

explanation  of  frequency,  391 
Rosenmiiller's  body,  42 
Rotation,  external,  anomalies  of,  404 
in  face  presentation,  412 
of  fetal  head,  398 

anomalies  of,  403 
external,  401 
of  occiput  in  face  presentation,  412 
in  occipitoposterior   j)osition,   404 
abnormaHtics  of,  40:5 
Rotheln  in  puerperal  state,  679 
Round  ligament  in  groin,  filjromvoma  of, 
in  j)regnancy,  225 
of   uterus,   shortening  of,   for  retro- 
displacement  of  uterus,  914 
Rubber  darn,  900 
gloves,  778 

sterilizing  of,  780 
Rupture  of  chorion,   119 

of  circular  sinus  of  placenta,  5S5 
of  Graafian  follicle,  61 
of  hematoma  in  labor,  623 
of  membranes,  artificial,  332 


Rupture  of  respiratory  tract  in  labor,  621 
of  sacro-iliac  joints  in  labor,  619 
of  symj)hysis  in  labor,  619 
of  umbilical  cord,  627 
of     uterus,     592.     See     also     Uterus, 

rupture  of. 
of  varicose  veins  in  pregnancy,  266 
of  vessels  in  cord,  140 


Sacculation  of  uterus,  218 

obstruction  of  labor  by,  542 

Sacral  plexuses,  lesions  of,  in  puerperal 
state,  692 
teratoma  of  fetus,  obstruction  of  labor 

by,  559  . 

Sacrococcygeal  joint,  ankylosis  of,  504 
fracture  of,  in  labor,  620 
rupture  of,  in  labor,  619 
synostosis  of,  504 
Sacrosciatic  ligaments,  27 
Sacrum,  fracture  of,  502 
Saddle-shaped  back,  508 
Saline  solutions  in  puerperal  sepsis,  740 
Salivation  in  pregnancy,  192 
Salpingectomy,  partial  technic  of,  910 

technic  of,  910 
Salpingitis  in  puerperal  sepsis,  753 
Salpingo-oophorectomy     for     puerperal 
sepsis,  745 
technic  of,  904 

of  ligating  broad  ligament  in,  907 
Sanger's  method  of  Cesarean  section,  858 
Sapremia  in  puerperal  sepsis,  764 
Sarcoma  of  vagina  in  pregnancy,  231 

of  vulva  in  pregnancy,  233 
Scalp,  injury  of,  during  labor,  935 
Scarlet  fever  in  puerperal  state,  674 
diagnosis,  676 
fref[uency,  674 
infection  and  incubation,  675 
peculiarities,  677 
prognosis,  677 
symptoms,  676 
of  fetus,  160 

relation  of,  to  puerperal  sejisis,  771 
Schatz's  method  of  ce])halic  version,  414 

metranoikter,  789 
Schede's   operation    for   urelc-ral    fistula, 

890 
Schultze's  method  of  arlifKial  rt'S])iration, 

940 
Sclerema  of  premature  infants,  929 
Scoliosis,  518 
Scoliotic  pelvis,  518 
Sebaceous    glands    of    Montgomery    in 

pregnancy,  195 
Sccondarv    alifluminal    prcgnancv,    285, 

30 1 
Seminal  fiuid,  67 

description  of,  67 
mechanism  of  ejaculation,  70 


986 


INDEX. 


Seminal  fluid,  mechanism  of  reception, 
within  genital  canal  of  female,  70 
spermatic  particles  in,  first  appear- 
ance, 70 
granule,  70 

of  spermatozoon,  67 
Seminiferous  tubules,  40 
Sepsis,  puerperal,   712.     See  also  Puer- 
peral sepsis. 
Septa  of  vagina,  obstruction  of  labor  by. 

Septic  cystitis  in  puerperal  sepsis,  766 
infection  of  lungs  of  new-born  infant, 
942 
of  umbilicus  of  new-born,  950 
metritis  in  puerperal  fever,  754 
proctitis  in  puerperal  sepsis,  768 
Septicemia  in  puerperal  sepsis,  764 
of  fetus,  162 
of  new-born  infant,  944 
Septum,  rectovaginal,  tear  of,  treatment, 

874 
Serum-therapy  in  puerperal  sepsis,  739 
Sex,  determination  of,  93,  213 
Sexual  organs,  female,  development,  39 
Shock  in  labor,  621,  642 

death  from,  621 
Shortening    round    ligament    for    retro- 
displacement  of  uterus,  914 
Shoulder    presentation,    426.     See    also 

Presentation,  shoulder. 
Shoulders,   descent,  rotation,   and  birth 

of,  401 
Show,  316 
Signs  of  pregnancy,  191 

ascertained  by  auscultation,  203 
by  inspection,  194 
by  touch,  200 
objective,  194 
subjective,  191 
Silkworm  gut,  preparation  of,  782 
Simple  flat  pelvis,  466 
Simpson's  cranioclast,  844 

forceps,  806,  807 
Sitz-pelvis,  524 
Skene's  ducts,  45 

Skin,  cleansing  of,  for  obstetric  operations, 
778 
diseases  in  pregnancy,  264 
in  puerperal  state,  686 
of  new-born,  947 
Skull,  fracture  of,  during  labor,  933 

injury  to,  during  labor,  933 
Skutsch's  method  of  pelvimetry,  460,  461 
Sloughs  of  scalp  of  infant  from  injury 

during  labor,  936 
Small-pox  in  puerperal  state,  679 

of  fetus,  159 
Smellie's  forceps,  802,  804 

perforator,  843,  844 
Sneguireff's   operation    for    making    coi- 
tional  vagina,  897 


Snufiies,  946 
Somatopleure,  79 
Sore  nipples,  706 
Soufiie,  funic,  204 

Spermatic   particle   and   ovule,    meeting 
place,  72 
in  semen,  first  appearance,  70 
Spermatozoa,  67 

meeting-place  of,  with  ovule,  72 

power  of  motion,  67 

time  of  disappearance,  from  semen  of 

old  men,  70 
vitality  of,  68 
Spermatozoon,  67 
Sphincter  ani,  lacerations  of,  treatment, 

867 
Spina  bifida,  treatment  of,  945 
Spinal  cord,   diseases  of,  in  pregnancy, 
.254 

inflammatory  diseases,  in  pregnancy, 
.      254 
paralyses  in  pregnancy,  254 
Spinelli's     operation     for     inversion     of 

uterus,  618 
Spirochaeta  pallida  in  fetal  syphilis,  157 

in  placenta,  129 
Splanchnopleure,  79 
Split  pelvis,  484 
Spondylizema,  511 
Spondylolisthesis,  505 
Spondylolisthetic  pelvis,   505.     See  also 

Pelvis,  spondylolisthetic. 
Spongy  layer  of  uterine  decidua,  147 
Spontaneous  abortion  of  gravid  uterus, 
218 
evolution,  432 

reposition  of  gravid  uterus,  218 
version,  432 
Sporadic  fetal  cretinism,  164 
Spurious  pregnancy,  214 
Stanton's  apparatus  for  measuring  blood- 
•   pressure,  631 

Staphylococci  in  puerperal  infection,  724 
Stein's   instrument    for    measuring    con- 
jugate, 452  _ 
Stenosis,  acquired,  of  vagina,  operations 
for,  893  _ 

of    umbilical     vein     associated     with 
cvstic  chorion,  118 
villi',  118 
vessels,  139 
Sterility,  causes  of,  75 
psychic,  76 
one-child,  76 
treatment  of,  76 
Sterilization  of  forceps,  811 
Sterilizer,  Rochester,  774 
Sterilizing  hands  and  skin,  778 
outfit,  773 
rubber  gloves,  780 
Stethoscope,  use  of,  in  diagnosing  preg- 
nancy, 204 


INDEX. 


987 


Still-births,  habit,  178 

repeated,  diagnosis  of  cause,  178 
Stillicidium,  575 
Stomach,  capacity  of,  in  new-born,  924 

diseases  of,  in  pregnancy,  237 

during  pregnancy,  237 

position  of,  in  new-born,  924 
Stone's  method  of  antepartum  fetometry, 

466 
Storm  abdominal  binder,  921 
Streptococcic  infection,  749 
Streptococcus     pyogenes     in     puerperal 

sepsis,  724,  727 
Striae,  mammary,  194 
Subcutaneous  emphysema  in  labor,  621 
Subinvolution  of  uterus,  645 
causes,  645 
diagnosis,  646 
treatment,  647 
Sublingual  cysts  in  new-born,  946 
Suburethral  abscess  in  pregnancy,  230 
Sugar  of  human  milk,  929 
Sun-stroke  in  puerperal  state,  671 
Superfetation,  95 
Superinvolution  of  uterus,  644 
Supernumerary  breasts,  693 

digits,  treatment  of,  944 
Supporting  perineum,  335 
Suppuration  of  pehac  joints,  769 

of  vulva,  obstruction  of  labor  by,  535 

pelvic,  vaginal  section  for,  752 
Suppurative  peritonitis,  diffuse,  abdomi- 
nal section  for,  744 
Fowler's  position  after  operation, 

for,  758 
Murphy's  treatment,  759 
Supravaginal  portion  of  uterus,  48 
Surgeon's  dress,  780 
Surgical  operations  in  pregnancy,  267 
Suspension  of  uterus  for  retrodisplace- 
ment,  918 
technic,  910 
Sutures,  preparation  of,  782 
Sway  back,  508 
Sweat    cabinet,     portable,     for    use     in 

eclampsia,  636 
Sweat-glands  in  puerperal  state,  359 
Symphyseotomy,  850 

by  French  method,  854 

by  Italian  method,  850 

Hirst's  canvas  binder  for,  854 

inriications  for,  8:^0 

technic  of,  850 
Symphysis  puVjis,  rupture  of,  in  labor,  619 

synostosis  of,  504 
Syncephalus,  craniotomy  for,  560 
Syncope  in  labor,  623 
Syncytial  cancer,  132 

relation  of,  to  mvxoma  of  chorion, 
116 
Syncytiolysin,  135 
S\Ticvtiums,  88,  120,  121 


Synostosis  of  pelvic  joints,  504 

of  sacro-iliac  joints,  504 
Syphilis,     fetal,     155.     See    also    Fetal 
syphilis. 

in  pregnancy,  264 

of  lungs  in  new-born  infant,  942 

of  new-born  infant,  943 

placental,  12S 
Syphilitic  fever  in  puerperal  state,  671 

infection  of  fetus,  155 

lesions  of  fetal  lungs,  157 

placentae,  129 
Syringe,  aseptic  metal  piston,  785 


Tampon,  insertion  of,  after  operation,  782 
Tarnier's  basiotribe,  845,  846 

axis-traction  forceps,  808 

sign  of  inevitable  abortion,  277 
Teeth,  caries  of,  in  pregnancy,  237 

in  pregnancy,  189 
Temperature  in  puerperal  state,  360 

of  fetus  in  utero,  90 

of  new-born  infant,  924 
Tenaculum,  Hirst's,  788 

Ulrich's,  883 
Teratoma,    sacral,  of  fetus,   obstruction 

of  labor  by,  559 
Tetanoid  con\'ulsions,  abortion  from,  270 
Tetanus  bacillus  in  puerperal  sepsis,  724 

in  puerperal  sepsis,  768 

of  new-born,  951 
Tetany  in  pregnancy,  255 
Theca  folliculi,  61 
Thigh    bones,   dislocation,  effect  of,   on 

7:)elvis,  522 
Third  stage  of  labor,  341 
mechanism,  433 

abnormalities  of,  434 
Thirst  after  delivery,  359 

in  puerperal  state,  359 
Thoracopagus,  birth  of,  558 
Thromlii,    displacement  of,  as  cause  of 

])uerperal  hemorrhage,  657 
Thrombophlebitis    in    puerperal    sepsis, 

74,3 
ligation    or   exsection   of  ovarian 
veins  in,  743 
Thrombosis  in  labor,  623 

of  pulmonarv  artery  in  labor,  623 
Thrush  of  new-born  infant,  946 
Thvroid  extract  in  eclampsia,  639 

gland,  changes  in,  in  pregnancy,  187 
Toothache  in  pregnancy,  237 
Thoraco])agus,  birth  of,  558 
Tongue-tie,  treatment  of,  944 
Torsion,  exaggerated,  of  umbilical  cord, 
1,38 
f)f  pregnant  uterus,  222 
Toxemia  as  an   indication  for  inducing 
abortion,  797 
in  pregnancy,  263 


988 


INDEX. 


Trachelorrhaphy,  897 

technic  of,  898 
Transmigration  of  ovum,  64 
Transverse    diameter    of    pelvic    outlet, 
measurement  of,  462 
of  pelvis,  22 

measurement,  460 
presentation,     426.     See     also     Pre- 
sentation. 
Transversely  contracted  pelvis,  482 
Traumatism,  fetal,  166 
Trimethylamin  in  vaginal  secretions,  722 
Trophoblast,  no 
True   conjugate,   measurement  of,   452, 

453 
corpus  luteum,  65 
Trunk  of  child,  injuries  of,  during  labor, 

937 
Tubal  abortion,  300 
moles,  299 
pregnancy,  285 

abdominal  section  for,  306 

atroph}^  of  sac  in,  295 

clinical  history,  287 

hematocele  from,  302 

pathology,  287 

rupture  of  sac  and  hemorrhage  of, 

295,  296  _ 
vaginal  section  for,  307 
varieties,  285 
Tubercle  bacillus  in  puerperal  sepsis,  724 
Tuberculosis,  miliary,  in  pregnancy,  262 
of  fetus,  161 
of  new-born  infant,  942 
of  placenta,  130 
pulmonary,  in  pregnancy,  262 
Tuberculous  endometritis,  153 
Tubo-abdominal  pregnancy,  301 
Tubo-ovarian  ligament,  53 
pregnancy,  285 

clinical  history,  291 
Tubo-uterine  pregnancy,  285 

terminations,  299 
Tumors,  abdominal,  abdominal  section 
for,  910 
pregnancv  and,  differentiation,  204 
mammary,  in  pregnancy,  236 
milk-,  711 
of  breast,  711 

of  broad  ligament   of  uterus,  enucle- 
ation of,  911 
of  fetus,  obstruction  of  labor  by,  558 
of  genital  canal,  obstruction  of  labor 

by,  545 

of  pelvis,  498 
of  placenta,  131 

symptoms,  135 

treatment,  136 
of  umbilical  cord,  143 
of  vagina   and   vulva,   obstruction   of 

labor  by,  535 
pelvic,  abdominal  section  for,  910 


Tumors,  pregnancy  and,  differentiation, 
204 
renal,  250 

in  pregnancy,  250 
Tunica  fibrosa  of  Graafian  follicle,  61 
media  of  Bischoff,  100 
propria  of  Graafian  follicle,  61 
Twin  labor,  565.     See  also  Labor,  twin. 
Tympanites  in  puerperal  state,  686 
Typhoid  fever  in  pregnancy,  263 
labor  complicated  by,  642 
of  fetus,  162 


Ulrich's  tenaculum,  883 
Umbilical  cord,  136 
anomalies  of,  138 
calcareous  degeneration  of,  142 
coiling  of,  around  fetus,  141 

in  twin  labor,  567 
cutting  of,  346 
'  cysts  of,  142 
description  of,  136 
development  of,  136 
exaggerated  torsion  of,  138 

twisting  of,  138 
false  knots  of,  138,  140 
hernia  of,  142 
in  new-born  infant,  925 
length  of,  138 
ligation  of,  345 

late,  345 
marginal  insertion  of,  141 
prolapse  of,  625 
reposition  of,  626 
rupture  of,  627 
short,  complicating  labor,  570 
true  knots  of,  140 
tumors  of,  143 
velamentous  insertion,  141 
fungi  in  new-born,  950 
-  hernia,  142 

of  new-born,  944 
vein,  stenosis  of,  associated  with  cystic 

degeneration  of  chorion  villi,  118 
vesicle,  136 
vessels,  136 

inflammation  of,  951 
rupture  of,  140 
stenosis  of,  139 
varices  of,  140 
Umbilicus,  changes  of,  in  pregnancy,  196 
hemorrhage  from,  951 
inflammation  of,  950 
of  new-born,  septic  infection  of,  926 
Undeveloped  pelvis,  476 
Urea,  excess  of,  in  maternal  blood,  effect 

of,  upon  fetus,  176 
Ureteral  anastomosis  for  ureteral  fistula, 
8S9 
fistula,  abdominal  operation  for,  891 
Bandl's  operation  for,  890 


INDEX. 


989 


Ureteral  fistula,  celio-uretero-cystostomy 
for,  889,  891 
celio-uretero-ureterostomy  for,  889 
colpoureterocystostomy  for,  889 
diagnosis  of,  880 
Dudley's  operation  for,  890 
implantation  of  ureter  into  Ijladder 

for,  891 
Mackenrodt's  operation  for,  890 
nephrectomy  for,  889 
Schede's  operation  for,  890 
treatment  of,  surgical,  888 
ureteral  anastomosis  for,  889 
vaginal  operation  for,  890 
Van  Hook's  lateral  invagination  for, 

891 
Witzel's  operation  for,  892 
Ureteritis  in  puerperal  sepsis,  766 
Uretero-uterine  fistula,  877 
UreteroVaginal  fistula,  877 
Ureters,  catheterization  of,  in  pregnancy, 
244 
cystoscopy  of,  in  pregnancy,  244 
implantation     of,     into     bladder,     for 

ureteral  fistula,  891 
surgical  injuries  of,  treatment,  888 
Urethral  fistula,  877 

orifice,  45 
Urethroscope,  245 
Urinalysis  in  pregnancy,  188,  245 
Urinary  and  genital  canals,   fistula   be- 
tween, 875 
apparatus,  diseases,  in  pregnancy,  244 
fistula,  875 

classification  of,  877 
system,  changes  in,  in  puerperal  state, 

358 
diseases  of,  in  puerperal  state,  687 
tract,  injuries  of,  in  labor,  619 
Urination  in  puerperal  state,  369 
Urine,  anomalies  of,  in  pregnancy,  252 
changesin,  in  pregnancy,  186 
diminution  of,  in  pregnancy,  252 
examination  of,  in  pregnancy,  188,  244 
excessive  secretion  of,  as  cause  of  hy- 

dramnios,  103 
in  eclampsia,  632 
in  new-lxjrn  infant,  924 
in  puerperal  state,  687 
incontinence    of,    after    operation    for 
vesicovaginal  fistula,  887,  888 
in  pregnancy,  252 
in  puerperal  state,  691 
of  mother  after  death  of  fetus,  1 73 
retention  of,  after  laV)or,  358 
Urogenital  sinus,  39,  40,  42 
Uterine  adnexa,  involution  of,  353 
artery,  32 
bruit,  203 

contractions  in  labor,  317 
decidua,  147 

compact  layer  of,  147 


Uterine  decidua,  glandular  layer  of,  147 
spongy  layer  of,  147 
hemorrhage  as  an  indication  for  in- 
ducing abortion,  798 
milk,  121 
mucous    membrane,    implantation    of 

ovum  in,  80 
muscle,  contractions,  in  labor,  317 
deficient   power  of,   439.     See  also 

Inertia  uteri. 
diseases  of,  222 

in  pregnancy,  222 
fibromyoma  of,  in  pregnancy,  223 
manner    in    which  it  acts  on  fetal 

body,  393 
new  growths  of,  in  pregnancy,  223 
phlebitis  in  puerperal  sepsis,  759 
segment,  lower,  392 
upper,  392 
Utero-abdominal  pregnancy,  285 

clinical  history,  293 
Utero-ovarian  ligament,  56 
Uterovesical  fistula,  877,  878 
Uterovesicovaginal  fistula,  S77 
Uterus,  abnormal  position  of,   abortion 
from,  270 
alterations  in,  in  pregnancy,  180 
anatomy  of,  46 

at  full  term,  181 
bicornis  duplex,  50 

non-pregnant  half,  hypertrophy  of, 

obstruction  of  labor  by,  548 
pregnancy  in  one  horn,  309 
unicollis,  53 
biforis,  53,  532 

blood-vessels,  in  pregnancy,  180 
broad  ligament  of,  technic  of  ligating, 
in  salpingo-oophorectomy,  907 
tumors  of,  enucleation,  911 
carcinoma  of,  in  pregnancy,  225 

puerperal  hemorrhage  from,  659 
changes  in,  in  extra-uterine  pregnancy, 
287 
in   form,    position,    direction,   topo- 
graphic relations    in    pregnancy, 
1S2 
in  volume,  capacity,  weight,  in  preg- 
nancy, 182 
conditions,    which   interfere   with   de- 
velopment of  fetus,  175 
congenital  anomalies  of,  obstru(  lion  of 

lalxjr  by,  530 
connective  tissue  in  pregnancy,  180 
contraction  of,  after  later,  method  of 

securing,  340 
cordiformis,  53 
deformities  of,  50 
riescent  of,  in  lalK)r,  315 
development  of,  41 
didelphys,  50 

non-pregnant  half,  hypertrophy  of, 
obstruction  of  labor  by,  548 


990 


INDEX. 


Uterus,   displacement    of,    anterior,   ob- 
struction of  labor  by,  539 

lateral  obstruction  of  labor  b}-,  542 

obstruction  of  labor  by,  538 

puerperal  hemorrhage  from,  653 
double,  obstruction  of  labor  by,  530 
elastic  tissue,  in  pregnancy,  180 
enlargement  of,  in  pregnancy,  202 
fibroids  of,  obstruction  of  labor  bv,  545 

puerperal  hemorrhage  from,  65S 
fibroma  of,  in  pregnancy,  223 
fixation  of,  obstruction  of  labor  by,  540 
hernia  of,  obstruction  of  labor  by,  539, 

540_ 
incudiformis,  53 
inversion  of,  in  labor,  611 
causes,  612 
prognosis,  618 
symptoms,  614 
treatment,  616 
involution  of,  348.     See  also  Involu- 
tion of  uterus. 
irritable,  as  cause  of  abortion,  268 
lymphatic  ducts  of,  in  pregnancy,  181 
muscle-fibers,  in  pregnancy,  180 
myoma  of,  vaginal  myomectomy  for, 

899 
nerves  of,  in  pregnancy,  181 
overdistention  of  abortion  from,  271 

as  cause  of  labor,  314 
peritoneal    covering,    changes    in,    in 

pregnancy,  180 
polypi  of,  obstruction  of  labor  by,  548 
position    of,    at   end    of    puerperium, 

382 
pregnant,  abortion  of,  218 

anteflexion  of,  215 
treatment,  216 

displacements  of,  215 

expulsion  of,  218 

forming  part  of  hernial  protrusion, 
222 

hernia  of,   obstruction  of  labor  bv, 

539.  540 

incarceration  of,  216,  218 
treatment,  219 

lateral  displacements,  220 

lateroflexion  of,  220 

lateroposition  of,  220 

lateroversion  of,  220 

prolapse  of,  220 

spontaneous  terminations,  221 
treatment,  222 

relation  of,  to  intestines,  183 

retroflexion  of,  216.     See  also  Retro- 
flexion. 

sacculation  of,  218 

spontaneous  reposition,  218 

torsion  of,  222 
prolapse  of,  complications  of  labor  by, 
542 

obstruction  of  labor  by,  542 


Uterus,  relaxation  of,  .as  cause  of  puer- 
peral hemorrhage,  658 
retrodisplacement  of,  abdominal  opera- 
tions for,  917 

Alquie-Alexander-Adams  operation 
for,  914 

Baldy's  operation  for,  918 

shortening  round  ligament  for,  914 

treatment,  911 

uterine  suspension  for,  918 
round    ligament    of,    shortening,    for 

retrodisplacement  of  uterus,  914 
rupture  of,  592 

causes,  593 

clinical  history,  597 

diagnosis,  597 

dift'erentiation,  from  accidental  hem- 
orrhage, 598 

frequency,  592 

in  pregnancy,  266 

morbid  anatomy,  594 

prognosis,  599 

symptoms,  597 

treatment,  600 
sacculation  of,  218 

obstruction  of  labor  by,  542 
semipartitus,  53 
subinvolution  of,  645.     See  also  Suh- 

involution. 
subseptus,  53 
superinvolution  of,  644 
suspension  of,  for    retrodisplacement, 
918 

technic,  910 
unicornis,  53 

pregnancy  in  one  horn,  309 


Vaccination,  intra-uterine,  159 
Vagina,  alterations  in,  in  pregnancy,  185 

anatomy  of,  45 

anterior  wall,  lacerations  of,  treatment, 

•    874 

appearance  of,  in  pregnancy,  199 

artificial,  Fleming's  operation  for  mak- 
ing, 895 

atresia  of,  hysterectomy  for,  896 
obstruction  of  labor  by,  535 
surgical  treatment,  894 

bacteria  of,  715-726 

bacteriology  of,  715-726 

carcinoma  of,  in  pregnancy,  231 

changes  in,  in  extra-uterine  pregnancy, 
287 

cicatrices  of,  obstruction  of  labor  by, 

534 
closure   of,    obstruction    of    labor   by, 

533 
coitional,  Isaac's  operation  for  making, 

^97  .       , 

Sneguireff's  operation   for   makmg, 

897 


INDEX. 


991 


Vagina,    congenital   narrowness   of,    ob- 
struction of  labor  by,  538 
development  of,  41 
diseases  of,  in  pregnancy,  227 
examination  of,  digital,  at  end  of  puer- 
perium,  380 
specular,  at  end  of  puerperium,  382 
gonococcus  infection  of,  in  pregnancy, 

227 
hematoma  of,  obstruction  of  labor  by, 

534 
in  pregnancy,  199 
lacerations  of,  in  labor,  604 
leukorrhea  of,  in  pregnancy,  227 
microbic  flora  of,  715-726 
mycosis  of,  in  pregnancy,  229 
operations  on,  indications  for,  867 
pathogenic     micro-organisms     in,     in 

pregnancy,  227 
posterior  wall,  lacerations  of,  Emmet's 
operation  for,  868-871 
treatment,  S67 
sarcoma  of,  in  pregnancy,  231 
septa  of,  obstruction  of  labor  by,  533 
stenosis  of,   acc[uired,   operations  for, 

893 
tumors  of,  obstruction  of  labor  by,  535 
varices  of,  in  pregnancy,  229 
Vaginal  Cesarean  section,  artificial  dila- 
tation of  cervical  canal  by,  795 
cysts  in  pregnancy,  231 
enterocele,  obstruction  of  labor  by,  552 
entrance,  lacerations  of,  in  labor,  607 
examination  for  diagnosis  of  presenting 

part,  390 
hernia,  obstruction  of  labor  by,  552 
hysterectomy,  technic  of,  904 
hysteromyomectomy,  technic  of,  899 
hysterotomy,  anterior,  artificial  dilata- 
tion of  cervical  canal  bv,  795 
leukorrhea  in  pregnancy,  227 
mucous   membrane,    colpohyperplasia 
of,  in  pregnancy,  228 
polypoid    hypertrophy,    in    preg- 
nancy, 229 
operation  for  ureteral  fistula,  S90 
preparation  for,  782,  864 
evening  before,  782 
morning  of  operation,  78 2 
portion  of  uterus,  48 
secretions,  germicidal   power,  of,  717- 

.7-3 
trimethyalmin  in,  722 

section    for    infection    of    pelvic    con- 
nective tissue,  752 
for  jjclvic  suppuration,  7^2 
for  tul)al  ])rcgnancy,  307 
technic  of,  S99 
wall,  anterior  injuries  of,  in  lalior,  610 
Vaginismus,  obstruction  of  labor  by,  538 

treatment  of,  864 
Vagitus  uterinus,  923 


\'an     Hook's    lateral    invagination    for 

ureteral  fistula,  891 
Van   Huevel's  method  of  treating  fetal 

hydrocephalus,  562 
\'arices  of  labia  majora  in  pregnancv,  231 
of  vagina  in  pregnancv,  229 
of  vessels  in  cord,  140 
old,  swelling  of,  as  indication  of  preg- 
nancy, 193 
Varicose  veins  in  pregnancy,  259 
rupture,  266 
obstruction  of  labor  by,  538 
Variola.     See  Small-pox. 
\^egetations  of  vulva  in  pregnancv,  231 
Velamentous  insertion  of  cord,  141 
Venereal  warts  of  vulva  in  pregnancy,  231 
Venesection  in  eclampsia,  637 
\'eratrum  viride  in  eclampsia,  638 
\'ernix  caseosa,  86 
X'ersion,  827 

by  external  manipulation,  829 
cephalic,  Baudeloccjue's  method,  414 

Schatz's  method,  414 
combined,  830 

D'Outrepont's  method  of,  831 
Wright's  method  of,  831 
contraindications  to,  828 
in  breech  presentation,  425 
in  contracted  pelves,  82 7 
in  labor  with  contracted  pelvis,  527 
in  shoulder  presentation,  433 
indications  for,  82 7 
podalic,  830 
postural,  8  29 
spontaneous,  432 
\'ertex  presentation,    395.     See   Presen- 
tation. 
\'esical  calculi  in  pregnancy,  252 
hemorrhoids  in  pregnancy,  252 
\'esicovag!nal  fistula,  877 
colpocleisis  in,  885,  886 
diagnosis  of,  879 
Ferguson's  operation  for,  S85 
in  labor,  619 
incontinence  of  urine  after  operation 

for,  88  7,  888 
intravesical  hemorrhage  after  opera- 
tion for,  888 
treatment  of,  881 
after  operation,  888 
operative,  883 
Vesicovestil:)ular  fistula,  877 
\'esi(ular  mole,  1 14 
\'cstil)ulo,  45 
bullis,  45 

lacerations  of,  in  labor,  607 
Vienna  operating  mask,  780 
Villi  of  chorion,   1  10 

cystic  degeneration,    iii.     See  also 

Cystic  degeneration. 
droj)sy  of,  iii 
of  placenta,  120 


992 


INDEX. 


Villi  of  placenta,  degeneration  of,  127 
Vision,  disturbances  of,  in  pregnancy,  256 
Vitelline  membrane,  62 
Vomiting,  abortion  from,  269 

as  indication  for  induction  of  abortion, 

797 
in  pregnancy,  192 
causes  of,  238 
diagnosis  of,  238 
mortality  from,  241 
pernicious,  237 
causes,  238 
diagnosis,  238 
treatment,  239 
gynecologic,  240 
hygienic,  239 
medicinal,  240 
obstetric,  241 
Voorhees'  bag,  786 

for   artificial   dilatation   of   cervical 

canal,  784 
in  placenta  priEvia,  579 
Vulva,  alterations  in,  in  pregnancy,  185 
appearance  of,  in  pregnancy,  199 
bacteria  of,  722 

carcinoma  of,  in  pregnancy,  233 
diseases  of,  in  pregnancy,  231 
edema  of,  in  pregnancy,  234 

obstruction  of  labor  by,  537 
elephantiasis  of,  obstruction  of  labor 
by,  535 
treatment,  867 
gangrene  of,  obstruction  of  labor  by, 

537 
in  labor,  321,  333 
in  pregnancy,  199 
inspection  of,  at  end  of    puerperium, 

377 
lacerations  of,  in  labor,  607 
operations  on,  indications  for,  864 
pointed  condyloma  of,  in  pregnancy, 

231 
pruritus  of,  exsection  of  vulvar  nerves 
for,  865 

in  pregnancy,  233,  265 
sarcoma  of,  in  pregnancy,  233 
suppuration   of,    obstruction   of   labor 

by,  535 
tumors  of,  obstruction  of  labor  by,  535 
vegetations  of,  in  jjregnancy,  231 
venereal  warts  of,  in  pregnancy,  231 


Vulvar  nerves,  exsection  of,  865 
Vulvovaginal  glands,  45 


Walcher  posture,  528,  529 

Warts,  venereal,  of  vulva,  in  pregnancy, 

231 
Washing  blood,  treatment  of  puerperal 

sepsis  by,  740 
Water  in  puerperal  sepsis,  733 
Webster's  operation  for  diastasis  of' recti 

muscle,  920 
Wegner's  sign  of  fetal  syphilis,  157 
Weight,  changes  in,  in  pregnancy,  187 
in  puerperal  state,  360 

loss  of,  after  labor,  360 

of  mature  fetus,  91 

of  new-born  infant,  923 
Wet-nurse,  selection  of,  929 
Wet-pack  in  eclampsia,  636 
Wharton's  gelatin,  137 
White  pneumonia  of  new-born,  939 
Wigand's    method    of    delivering    after- 
coming  head,  838 

treatment  of  placenta  prsevia,  581 
Williams'  pelvimeter,  465 
Winckel's  disease,  950 
Witzel's    operation    for    ureteral    fistula, 

892 
Wolffian  body,  40—42 

ducts,  39,  40 
Womb.     See  Uterus. 
Wormian  bones,  obstruction  of  labor  bv, 

Wounds  in  genital  tract,  puerperal  hem- 
orrhage from,  659 
Wright's   method   of   combined   version, 

831 
Wylie's  method  of  instrumental  dilata- 
tion of  cervical  canal,  789 


Xiphopagus,  556 
birth  of,  558 


Yellow  fever  of  fetus,  162 
Yolk  of  ovum,  62 


Zona  pellucida,  62 


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